Independent Health's
Encompass® 65 HMO
(without prescription coverage)
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Here is an outline of some of the specific changes in your current plan for 2018.

You can also review your Annual Notice of Change / Evidence of Coverage for a complete list of plan changes and 2018 benefits:
2017 2018
Monthly Premium $0 $0
Part D Prescription Benefit No Prescription benefit No Prescription benefit
Primary Copay $5 $0
Specialty Copay $25 $25
Inpatient Hospital Copay Days 1-6: $300 copay per day
Days 7-90: $0
Days 1-6: $275 per day
Days 7-90: $0 per day
$1,800 annual member copay maximum
Worldwide Emergency and Urgent Care* $75 / $65 $80 / $65
Lab Copay** $5 $0
General X-ray / Advanced Radiology Copay General X-ray: $25 copay
Advanced Radiology: $50 copay
General X-ray: $25 copay
Advanced Radiology: $50 copay
PREMIER WELLNESS PACKAGE***:  
Vision
(from a network provider)
$20 routine eye exam
$150 coverage limit for routine eyewear
$0 routine eye exam
$200 coverage limit for routine eyewear
Preventive Dental
(from a network provider)†
$20 per visit preventive dental: Two routine cleanings, exams and bitewing X-rays per calendar year. One full-mouth series every 36 months. $20 per visit preventive dental: Two routine cleanings, exams and bitewing X-rays per calendar year.
One full-mouth series every 36 months.
Gym Membership
(from a network provider)
Healthy Benefits Gym Membership for one calendar year. ($30 activation fee) Healthy Benefits Gym Membership for one calendar year. ( $20 activation fee)
Hearing Aid Benefit
(from a network provider)†
$45 hearing aid evaluation exam. Member pays $699 or $999 (per ear/per year) for hearing aid devices. The cost of these hearing aids without coverage is $1,850 or $2,995 per ear. $45 hearing aid evaluation exam. Member pays: $699 or $999 (per ear) for hearing aid device. The average cost for hearing aids without coverage is $1,850 or $2,995 per ear.
Enhanced Annual Wellness Visit (EAV)† $0 $0
New! Telemedicine
(from a network provider)
Not offered. $45 copay per session. Speak with a doctor anytime, anywhere by phone or online.
FitWorks Medicare Earn a $50 TOPS gift card for living healthy. See your doctor, get screenings, get active - get rewarded! Earn a $50 TOPS gift card for living healthy. See your doctor, get screenings, get active - get rewarded!

Disclaimers
Independent Health is a Medicare Advantage organization with a Medicare contract offering HMO, HMO-SNP, HMO-POS and PPO plans. Enrollment in Independent Health depends on contract renewal.
*$10,000 annual maximum plan limit for emergency care, urgent care or ambulance outside the USA and its territories.
**Member pays 20% of the cost of genetic testing.
***Limitations, copayments and restrictions may apply. Applicable copays may apply for these benefits. Member must use in-network providers to take advantage of these benefits (excluding Independent Health’s Medicare Passport Advantage PPO plan). Must see a TruHearing provider to use the hearing aid benefit.
†Excludes Independent Health’s Medicare Family Choice HMO-SNP. Benefits vary by plan and some plans do not include coverage for these benefits. Benefits, premiums, rewards and/or copayments may change on January 1 of each year. This information is not a complete description of benefits. Contact the plan for more information. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. This chart is for general reference and is not a contract. See Evidence of Coverage for complete details. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.
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Y0042_C5900 Approved 11052017
Last Updated 11/8/2017