2027 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

$15

PRIMARY/SPECIALTY COPAY

(In-Network)

$0/$0

for cardiologist, endocrinologist and nephrologist. $25 for all other specialties.

INPATIENT HOSPITAL COPAY

(In-Network)

Days 1-5: $400 per day. Additional days: $0 Unlimited Days for Medicare covered stays. (No Maximum Annual Member Copay Limit).

PART D PRESCRIPTION BENEFIT

$250 deductible on tiers 3, 4 & 5 only. $0/$8/19%/37%/30% to Catastrophic Coverage Limit of $2,400. $35 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

$15

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

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

$250 deductible on tiers 3, 4 and 5. $0/$8/$19/37%/30% to Catastrophic Coverage Limit of $2,400.

Primary Copay

Specialty Copay

$0 for endocrinologist, cardiologist and nephrologist. $25 for other specialists.

Preventive Services

Inpatient Hospital Copay

Days 1-5: $400 per day. Additional days: $0. Unlimited Days for Medicare covered stays. (No Annual Member Copay Maximum).

Ambulance

20% coinsurance

Emergency / Urgent Care

$115 / $40

Lab Copay*

General X-ray / Advanced Radiology Copay

General X-ray: $30

Advanced Radiology: $175

Speech, Physical, Occupational Therapy

$15

Skilled Nursing Facility

Days 1 - 20: $0

Days 21 - 100: $221 per day

Annual Out-of-Pocket Maximum for Medicare Covered Services

$8,500

Wellness Benefits

Dental

$2,000 combined maximum for preventive dental and comprehensive dental in-network and out-of-network.

Preventive Dental: $0 per visit with a Liberty Dental provider for preventive dental. Two routine cleanings, exams, fluoride treatments and bitewing X-rays per calendar year. One full-mouth series every 36 months.

Comprehensive Dental: 50% coinsurance with a Liberty Dental provider.

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

$0 copayment (Memberships will not roll over from 2026 to 2027 or 2027 to 2028. Memberships will restart on January 1st of each year.)

Vision (from a network provider)

$0 routine eye exam. $200 annual allowance for routine eyewear.

Hearing Aid Benefit (from a network provider)

$45 hearing aid evaluation exam. $250 allowance per ear for hearing aids. Member pays: $499 - $1,949 price per hearing aid. The average cost for hearing aids without coverage is $2,445 - $3,125 per ear.

Personal Emergency Response System (PERS)

Additional Wellness Benefits

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

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.

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

Independent Health has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until December 31, 2027 based on a review of Independent Health’s Model of Care.

Y0042_C7173
Last Updated 10/1/2026

Individuals & Families

Individuals & Families

In the Community

Brokers

Providers

Employers

2027 Assure Advantage^® HMO C-SNP Plan

MONTHLY PREMIUM

PRIMARY/SPECIALTY COPAY

(In-Network)

INPATIENT HOSPITAL COPAY

(In-Network)

PART D PRESCRIPTION BENEFIT

(Tier 1 / 2 / 3 / 4 / 5)

MONTHLY PREMIUM

$15

PRIMARY/SPECIALTY COPAY

(In-Network)

$0/$0

INPATIENT HOSPITAL COPAY

(In-Network)

PART D PRESCRIPTION BENEFIT

Plan Details

Wellness Benefits

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Individuals & Families

Individuals & Families

In the Community

Brokers

Providers

Employers

2027 Assure Advantage® HMO C-SNP Plan

MONTHLY PREMIUM

PRIMARY/SPECIALTY COPAY

(In-Network)

INPATIENT HOSPITAL COPAY

(In-Network)

PART D PRESCRIPTION BENEFIT

(Tier 1 / 2 / 3 / 4 / 5)

MONTHLY PREMIUM

$15

PRIMARY/SPECIALTY COPAY

(In-Network)

$0/$0

INPATIENT HOSPITAL COPAY

(In-Network)

PART D PRESCRIPTION BENEFIT

Plan Details

Wellness Benefits

2027 Assure Advantage^® HMO C-SNP Plan