The Health Plan SecureCare - Option II (HMO)

The Health Plan SecureCare - Option II (HMO) H3672-013 Plan Details
4 out of 5 stars

The Health Plan SecureCare - Option II (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Health Plan of the Upper Ohio Valley.
Plan ID: H3672-013.

$0.00
Monthly Premium

The Health Plan SecureCare - Option II (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Health Plan of the Upper Ohio Valley.
Plan ID: H3672-013.

The Health Plan SecureCare - Option II (HMO) H3672-013 Plan Details
4 out of 5 stars

The Health Plan SecureCare - Option II (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Health Plan of the Upper Ohio Valley.
Plan ID: H3672-013.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $100
Out of Pocket Max In-Network: $3900
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$265.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $45.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $200.00 to $500.00
Maximum Plan Benefit of $25,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $200.00

Air Ambulance:
Copayment for Air Ambulance Services $500.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

The Health Plan SecureCare - Option II (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $7.50
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $50.00
Copayment for Medicare-covered Lab Services $0.00

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $150.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $50.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$265.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $250.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $250.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $45.00
Copayment for Medicare-covered Group Sessions $45.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $60.00 every three months
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $45.00
Copayment for Routine Foot Care $45.00
  • Maximum 2 visits every year
Prior Authorization Required for Podiatry Services
Prior authorization required
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$160.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Comprehensive Dental:
Copayment for Medicare-covered Benefits $45.00
Coinsurance for Restorative Services 20% to 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Endodontics 50%
Coinsurance for Periodontics 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Extractions 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1000.00 every year for Non-Medicare Covered Comprehensive
Prior Authorization Required for Comprehensive Dental
Prior authorization required

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
  • Maximum 1 Pair every two years
Copayment for Eyeglass Lenses $0.00
  • Maximum 1 Pair every two years
Copayment for Eyeglass Frames $0.00
  • Maximum 1 Pair every two years
Maximum Plan Benefit of $100.00 every two years for all Non-Medicare covered eyewear

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $45.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $599.00 to $899.00
  • Maximum 2 Hearing Aids every two years
Up to two TruHearing-branded hearing aids every 2 years (one per ear every 2 years). Benefit is limited to TruHearing's Advanced and Premium hearing aids, which come in various styles and colors. Premium hearing aids are available in rechargeable style options for an additional $50 per aid. You must see a TruHearing provider to use this benefit. Hearing aid purchase includes: - First year of follow-up provider visits - 60-day trial period - 3-year extended warranty - 2-year supply of batteries per hearing aid for non-rechargeable models Benefit does not include or cover any of the following: - Additional cost for optional hearing aid rechargeability - Ear molds - Hearing aid accessories - Additional provider visits - Additional batteries, batteries when a rechargeable hearing aid is purchased - Hearing aids that are not TruHearing-branded hearing aids - Costs associated with loss and damage warranty claims Costs associated with excluded items are th

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The The Health Plan SecureCare - Option II (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $100 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $100 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $3.00
    • Standard retail $13.00
    • Preferred mail order $3.00
    • Standard mail order $13.00
    Generic
    • Preferred retail $10.00
    • Standard retail $20.00
    • Preferred mail order $10.00
    • Standard mail order $20.00
    Annual Drug Deductible $100 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $6.00
    • Standard retail $26.00
    • Preferred mail order $0.00
    • Standard mail order $26.00
    Generic
    • Preferred retail $20.00
    • Standard retail $40.00
    • Preferred mail order $0.00
    • Standard mail order $40.00
    Annual Drug Deductible $100 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $9.00
    • Standard retail $39.00
    • Preferred mail order $0.00
    • Standard mail order $39.00
    Generic
    • Preferred retail $30.00
    • Standard retail $60.00
    • Preferred mail order $0.00
    • Standard mail order $60.00