2022 Encompass 65® Edge HMO

Give Back 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

$0

(Independent Health pays $30 per month toward your Part B premium)

PRIMARY/SPECIALTY COPAY
(In-Network)

$25/$50

INPATIENT HOSPITAL COPAY
(In-Network)

Days 1-5: $400 per day. Additional days: $0. Unlimited Days for Medicare covered stays. (There is NOT an Annual Member Copay Maximum).

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

$480 deductible on tiers 3, 4 & 5 only. $3/$20/$47/41%/25% to initial coverage limit of $4,430.

Plan Details

Monthly Premium

$0 (Independent Health pays $30 per month toward your Part B premium)

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

$480 deductible on tiers 3, 4 & 5 only. $3/$20/$47/41%/25% to initial coverage limit of $4,430.

Primary Copay

$25

Specialty Copay

$50

Inpatient Hospital Copay

Days 1-5: $400 per day. Additional days: $0. Unlimited Days for Medicare covered stays. (There is Not an Annual Member Copay Maximum).

Worldwide Emergency / Urgent Care*

$90 / $65

Lab Copay**

$20

General X-ray / Advanced Radiology Copay

$50 / $300

Premier Wellness Package***

Vision (from a network provider)

$0 routine eye exam. $150 coverage limit for routine eyewear every 2 years. $0 for diabetic retinopathy exam for diabetics. $0 for Ophthalmologist too.

Dental (from a network provider)

Preventive dental is included in optional supplemental dental benefit. 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 or $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

Telemedicine (from a network provider)

$25 copay per session. Speak with a doctor anytime, anywhere by phone or online.

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

Disclaimers

* $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 or Independent Health’s Medicare Passport Prime PPO plan). Must see a Start Hearing network provider to use the hearing aid benefit.

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. Call (716) 250-4401 or 1-800-665-1502 (TTY users call 711) for more information.

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

Y0042_C7173
Last Updated 10/01/2021