Medicare Advantage plan options and details

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2022 benefit overview

See our 2022 additional benefits page for more information.

Prevea Essential

Monthly Premium

Part B premium reduction

$25 monthly Part B premium reduction
Hospital copay per day

In-network: $325/day for days 1-5 Out-of-network: $500/day for days 1-7
Primary care copay

In-network: $0 Out-of-network: $50
Specialist visit copay

In-network: $35 Out-of-network: $50
Emergency room copay

$90
Urgent care copay

$35
Ambulance

In-network: $275 Out-of-network: $275
Therapy (physical, occupation, and speech)

In-network: $35 Out-of-network: $60
Durable medical equipment

In-network: 20% Out-of-network: 40%
Outpatient surgery

In-network: $275 Out-of-network: 20% coinsurance
Maximum out-of-pocket

In-network: $4500 Out-of-network: $6000

Prevea Harmony

Monthly Premium

Part B premium reduction

$50 monthly Part B premium reduction
Hospital copay per day

In-network: $325/day for days 1-5 Out-of-network: $500/day for days 1-7
Primary care copay

In-network: $0 Out-of-network: $50
Specialist copay

In-network: $35 Out-of-network: $50
Emergency room copay

$90
Urgent care copay

$35
Ambulance

In-network: $275 Out-of-network: $275
Therapy (physical, occupation, and speech)

In-network: $35 Out-of-network: $60
Durable medical equipment

In-network: 20% Out-of-network: 40%
Outpatient surgery

In-network: $275 Out-of-network: 20% coinsurance
Maximum out-of-pocket

In-network: $4500 Out-of-network: $6000

2022 additional benefit overview

All plans include:

additional benefits

Preventive & comprehensive dental

• No waiting period, no deductibles or coinsurance
• Preventive and diagnostic services: $0 copay
• Gum disease maintenance and bridge/implants/dentures repairs: $45 copay
• Fillings, non-surgical gum disease treatment and extractions: $95 copay
• Root canals, bridges, implants, dentures, crowns, & surgical gum disease treatment: $595 copay
• $1,500 in dental services covered per year
In-home and virtual support

Visits in your home or virtually for up to 10 hours per month
Over-the-counter items

• $50 per quarter to spend on eligible over-the-counter products like bandages, pain relievers and much more
• In-store at participating retailers including Walgreens, CVS, Walmart, Dollar General and Kroger stores
• Online at OTCNetwork.com
• Mail-order catalog
Hearing

One $0 routine hearing exam and a $750 hearing aid allowance per year at in-network hearing aid providers
Vision

One $0 routine vision exam and a $200 eyewear allowance per year at in-network eyeglass providers
Transportation

We partnered with Lyft to cover 24 one-way personal rides each year to medical appointments and to the pharmacy
Post discharge meals

14 meals from Mom’s Meals delivered to your door after you are discharged from the hospital or a skilled nursing facility
Fitness benefits

The Silver&Fit® program includes:
• Fitness center memberships
• Home fitness kit with a Fitbit, Garmin or other exercise equipment
• 8,000+ on-demand videos
Nurse line (Prevea After Hours)

Nurses are available for free 24 hours a day, 365 days a year
Living healthy rewards

Earn up to $150 in rewards for completing healthy activities like receiving a flu shot, going to the dentist and getting an annual physical

2022 Part D benefit overview

	Essential
	Deductible (applies to tiers 3-5): $250
	1 month/30 days	3 month/90 days
Preferred retail and mail order	Tier 1: $0 Tier 2: $5 Tier 3: $40 Tier 4: $90 Tier 5: 28% cost sharing	Tier 1: $0 Tier 2: $10 Tier 3: $100 Tier 4: $270 Tier 5:not applicable
Standard retail	Tier 1: $7 Tier 2: $12 Tier 3: $47 Tier 4: $100 Tier 5: 28% cost sharing	Tier 1: $7 Tier 2: $24 Tier 3: $117.50 Tier 4: $300 Tier 5: not applicable
Coverage gap (donut hole)	25% coinsurance
Catastrophic coverage	Generic: 5% or $3.95 Brand: 5% or $9.85

Harmony (HMO-POS) MA only:

Prevea360 Harmony does not offer Part D Prescription Harmony (HMO POS) MA Only Drug coverage. This is an excellent choice if you already have prescription drug coverage through Wisconsin’s Senior Care Prescription Drug Assistance Program, TRICARE for Life, the VA or an employer plan. You cannot have a Medicare Part D Prescription Drug plan if you enroll in the Harmony plan.

Shop 2022 plans