2027 Encompass 65® RED 042 HMO

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

$49

PRIMARY/SPECIALTY COPAY

(In-Network)

$0/$55

INPATIENT HOSPITAL COPAY

(In-Network)

$350 deductible then $530 per day for days 1 through 4. $0 copay for days 5 through 90. Unlimited days. $6,068 copay maximum.

PART D PRESCRIPTION BENEFIT

$550 deductible on tiers 3, 4 & 5 only. $0/$5/18%/33%/27% to Catastrophic Coverage Limit of $2,400.

Plan Details

Monthly Premium

$49

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

$8.50

Annual Medical Deductible (on certain services)

$350

Part D Prescription Benefit Tier 1 / 2 / 3 / 4 / 5 (uses Standard formulary)

$550 deductible on tiers 3, 4 & 5 only. $0/$5/18%/33%/27% to Catastrophic Coverage Limit of $2,400.

Primary Copay

Specialty Copay

$55

Preventive Services

Inpatient Hospital Copay

Deductible then $530 per day for days 1 - 4.

Additional days: $0. Unlimited Days for Medicare covered stays. ($6,068 Annual Member Copay Maximum).

Outpatient Mental Health Care Copay

$35

Worldwide Emergency / Urgent Care*

$115 / $40

Ambulance Copay

Ground: Deductible then $270

Lab Copay**

General X-ray / Advanced Radiology Copay

$55 / Deductible then $325

Outpatient Surgery

Ambulatory Surgical Center: Deductible then $350

Hospital-based: Deductible then $500

Skilled Nursing Facility

Deductible then:

Days 1 - 20: $0 per day

Days 21 - 100: $221 per day

Home Health

Physical, Speech and Occupational Therapy

$20

Part B Medications

Deductible then 0% - 20%

Annual Out-of-Pocket Maximum for Medicare Covered Services

$9,850

Wellness Benefits†

Dental

$1,500 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.

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 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.

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 Copay

$15 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 deductible then 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 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® RED 042 HMO

MONTHLY PREMIUM

PRIMARY/SPECIALTY COPAY

(In-Network)

INPATIENT HOSPITAL COPAY

(In-Network)

PART D PRESCRIPTION BENEFIT

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

MONTHLY PREMIUM

$49

PRIMARY/SPECIALTY COPAY

(In-Network)

$0/$55

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® RED 042 HMO

MONTHLY PREMIUM

PRIMARY/SPECIALTY COPAY

(In-Network)

INPATIENT HOSPITAL COPAY

(In-Network)

PART D PRESCRIPTION BENEFIT

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

MONTHLY PREMIUM

$49

PRIMARY/SPECIALTY COPAY

(In-Network)

$0/$55

INPATIENT HOSPITAL COPAY

(In-Network)

PART D PRESCRIPTION BENEFIT

Plan Details

Wellness Benefits†