2022 Assure Advantage® HMO C-SNP Plan

Plan Highlights

MONTHLY PREMIUM
PRIMARY/SPECIALTY COPAY
(In-Network)
INPATIENT HOSPITAL COPAY
(In-Network)
PART D PRESCRIPTION BENEFIT
(Tier 1 / 2 / 3 / 4 / 5)
MONTHLY PREMIUM

$60

PRIMARY/SPECIALTY COPAY
(In-Network)

$0/$30

INPATIENT HOSPITAL COPAY
(In-Network)

Days 1-6: $275 per day. Additional days: $0 Unlimited Days for Medicare covered stays. ($1,925 Annual Member Copay Maximum).

PART D PRESCRIPTION BENEFIT
(Tier 1 / 2 / 3 / 4 / 5)

No deductible. $0/$12/$47/38%/33% to initial coverage limit of $4,430. $15 for insulins on our formulary.

Plan Details

Independent Health’s Assure Advantage (HMO-SNP) is a specialized Medicare Advantage Plan (a Medicare “Special Needs Plan”), which means its benefits are designed for people with special health care needs. Independent Health’s Assure Advantage is designed to provide additional health benefits that specifically help people who have chronic heart failure.

Our plan includes providers who specialize in treating chronic heart failure. It also includes health programs designed to serve the specialized needs of people with this condition. In addition, our plan covers prescription drugs to treat most medical conditions, including the drugs that are usually used to treat chronic heart failure. As a member of the plan, you get benefits specially tailored to your condition and have all your care coordinated through our plan.

Eligibility Requirements:
To be eligible, it’s important that you meet all of the following criteria:

  • Reside in Erie County.
  • Have chronic heart failure.
  • Must be entitled or enrolled in Medicare Parts A and B.

Note: Enrollment into Independent Health’s Assure Advantage HMO-SNP plan will automatically disenroll a person from any other Medicare Advantage plan.

For more information or to enroll speak with an Independent Health representative today at:
(716) 635-4900 or 1-800-958-4405 (TTY users call 711):
October 1 – March 31: Monday – Sunday, 8 a.m. – 8 p.m.
April 1 – September 30: Monday – Friday, 8 a.m. – 8 p.m.

Monthly Premium

$60

Plan Premium with Full 100% Low Income Subsidy (LIS)

$17.60

Part D Prescription Benefit Tier 1 / 2 / 3 / 4 / 5 / 6

No deductible. $0/$12/$47/38%/33% to initial coverage limit of $4,430.  $15 for insulins on our formulary.

Primary Copay

$0

Specialty Copay

$30

Inpatient Hospital Copay

Days 1-6: $275 per day. Additional days: $0 Unlimited Days for Medicare covered stays. ($1,925 Annual Member Copay Maximum).

Worldwide Emergency / Urgent Care**

$90 / $65

Lab Copay*

$0

General X-ray / Advanced Radiology Copay

$30 / $200

Transportation (from a network provider)

$0 for up to 12 one-way trips to plan-approved locations (30-mile limit per trip).

NEW! Over-the-Counter***

$50 per quarter

Premier Wellness Package

Vision (from a network provider)

$0 routine eye exam. $150 coverage limit for routine eyewear. $0 for diabetic retinopathy exam for diabetics. $0 for Ophthalmologist too.

Dental (from a network provider)

$20 per visit for preventive dental: Two routine cleanings, exams, fluoride treatments and bitewing X-rays per calendar year. One full-mouth series every 36 months. Optional supplemental dental: 1 option offered for additional $25 premium billed separately. $750 every 3 months - Jan, April, July, Oct. $3,000 max limit, $0 deductible, 50% coinsurance.

SilverSneakers® Fitness Benefit (from a participating facility that offers SilverSneakers)

$0 copayment (memberships will not roll over from 2021 to 2022 or 2022 to 2023. Memberships will restart on January 1st of each year).

Hearing Aid Benefit (from a network provider)

$45 hearing aid evaluation exam. Member pays: $499 - $2,799 (per ear) for hearing aid device. The average cost for hearing aids without coverage is $2,445 or $3,125 per ear.

Enhanced Annual Wellness Visit (EAV)

$0

All of our Medicare Advantage plans come with additional benefits to help you maintain an active, healthy lifestyle.

Disclaimers

* Member pays 20% for genetic testing.

This plan requires the use of participating providers, except in the case of emergency care, urgent care or out of area renal dialysis. This information is not a complete description of benefits. Call (716) 250-4401 or 1-800-665-1502 (TTY users call 711) for more information.

** $10,000 annual maximum plan limit for emergency care, urgent care or ambulance outside the USA and its territories.

***Allowance is made available by quarter. Allowance does not carry over quarter to quarter or plan year to plan year. Costs over the allowed amount are the member’s responsibility. This benefit can only be used for covered items through NationsOTC.®

IN = In-Network, OON = Out-of-Network

Y0042_C7173
Last Updated 10/01/2021