2027 Encompass 65® HMO (without prescription coverage)

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 $60 per month toward your Part B premium)

PRIMARY/SPECIALTY COPAY

(In-Network)

$0/$30

INPATIENT HOSPITAL COPAY

(In-Network)

Days 1-5: $300 per day. Additional days: $0. Unlimited Days for Medicare covered stays. ($1,500 Annual Member Copay Maximum).

PART D PRESCRIPTION BENEFIT

No Part D prescription drug benefit.

Plan Details

Monthly Premium

$0 (note: there is a $60 Part B premium giveback with this plan)

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

No Part D prescription drug benefit.

Primary Copay

Specialty Copay

$30

Preventive Services

Inpatient Hospital Copay

$300 per day for days 1 through 5. $0 per day for days 6 through 90. Unlimited Days for Medicare covered stays. (Annual Member Copay Maximum $1,500).

Outpatient Mental Health Care

$20

Worldwide Emergency / Urgent Care*

$130 / $50

Ambulance

Ground: $275 copay

Non-Emergency Transportation

$0 for 24 one-way trips. Unlimited trips to/from VA Facilities.

Personal Emergency Response System (PERS)

Lab Copay**

General X-ray / Advanced Radiology Copay

$35 / $150

Outpatient Surgery

Ambulatory Surgical Center: $300

Hospital-based: $300

Skilled Nursing Facility

Days 1 - 20: $0

Days 21 - 100: $221 per day

Home Health

Physical, Speech and Occupational Therapy

$35

Part B Medications

0% - 20%

Annual Out-of-Pocket Maximum for Medicare Covered Services

$6,750

Wellness Benefits†

Dental

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

Preventive Dental: $0 per visit to 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.

Over-the-Counter (OTC)***

$75 per quarter

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 allowance for routine eyewear.

Hearing Aid Benefit (from a network provider)

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

Telemedicine (with a Teladoc® provider)

$0 copay per session. Speak with a doctor anytime, anywhere by phone or online. Behavioral Health is covered at $0 copay also.

Chiropractic Services

$10 for Chiropractic evaluation, management and Medicare covered services

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

* $10,000 maximum per occurrence for emergency care, urgent care or ambulance outside the USA and its territories.

** Member pays 20% of the cost of genetic testing.

***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.^®

† 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 Connect 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 10/1/2026

Individuals & Families

Individuals & Families

In the Community

Brokers

Providers

Employers

2027 Encompass 65® HMO (without prescription coverage)

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

PRIMARY/SPECIALTY COPAY

(In-Network)

$0/$30

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 Encompass 65® HMO (without prescription coverage)

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

PRIMARY/SPECIALTY COPAY

(In-Network)

$0/$30

INPATIENT HOSPITAL COPAY

(In-Network)

PART D PRESCRIPTION BENEFIT

Plan Details

Wellness Benefits†