Medicare Advantage plan options and details


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2023 benefit overview

See our 2023 additional benefits page for more information.

Prevea Essential

$
0
Monthly Premium
  • Hospital copay
    In-network: $350/day for days 1-5
    Out-of-network: $600/day for days 1-7
  • Primary care copay
    In-network: $0
    Out-of-network: $60
  • Specialist copay
    In-network: $35
    Out-of-network: $60
  • Emergency room copay
    $95
  • Urgent care copay
    $35
  • Ground ambulance
    $275
  • Therapy (physical, occupation, and speech)
    In-network: $40
    Out-of-network: $60
  • Outpatient surgery
    In-network: $350
    Out-of-network: 40% coinsurance
  • Maximum out-of-pocket
    In-network: $4700
    Out-of-network: $6000

Prevea FlexSpend

$
0
Monthly Premium
  • Hospital copay
    In-network: $350/day for days 1-5
    Out-of-network: $600/day for days 1-7
  • Primary care copay
    In-network: $0
    Out-of-network: $60
  • Specialist copay
    In-network: $35
    Out-of-network: $60
  • Emergency room copay
    $95
  • Urgent care copay
    $35
  • Ground ambulance
    $275
  • Therapy (physical, occupation, and speech)
    In-network: $40
    Out-of-network: $60
  • Outpatient surgery
    In-network: $350
    Out-of-network: 40% coinsurance
  • Maximum out-of-pocket
    In-network: $4700
    Out-of-network: $6000

Prevea Harmony

$
0
Monthly Premium
  • Hospital copay per day
    In-network: $350/day for days 1-5
    Out-of-network: $600/day for days 1-7
  • Primary care copay
    In-network: $0
    Out-of-network: $60
  • Specialist copay
    In-network: $35
    Out-of-network: $60
  • Emergency room copay
    $110
  • Urgent care copay
    $35
  • Ground ambulance
    $275
  • Therapy (physical, occupation, and speech)
    In-network: $40
    Out-of-network: $60
  • Outpatient surgery
    In-network: $350
    Out-of-network: 40% coinsurance
  • Maximum out-of-pocket
    In-network: $4700
    Out-of-network: $6000


2023 additional benefit overview

All plans:

  • No waiting period, no deductibles or coinsurance
  • Preventive and diagnostic services: $0 copay

Preavea360 Essential and Prevea360 Harmony:

  • 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

Prevea360 FlexSpend:

  • Gum disease maintenance and bridge/implants/dentures repairs: 50% coinsurance
  • Fillings, non-surgical gum disease treatment and extractions: 50% coinsurance
  • Root canals, bridges, implants, dentures, crowns, & surgical gum disease treatment: 50% coinsurance
  • $300 in dental services covered per year
You can also spend any amount of your $650 FlexSpend benefit on dental services at in or out-of-network locations.
  • Visits in your home or virtually for up to 120 hours per months
  • $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
  • One $0 routine hearing exam and a $750 hearing aid allowance per year at in-network hearing aid providers.
  • All plans: one $0 routine vision exam per year.
  • Prevea360 Essential and Prevea Harmony: $150 eyewear benefit at in-network and stand alone vision centers.
  • Prevea360 FlexSpend: You can spend any amount of your $650 FlexSpend benefit on eyewear at in-network and stand alone vision centers.

All plans:

  • We partnered with Lyft to cover 24 one-way personal rides each year to medical appointments and to the pharmacy.
  • 14 meals from Mom’s Meals delivered to your door after you are discharged from the hospital or a skilled nursing facility.

The One Pass™ program includes:

  • Fitness center memberships
  • Home fitness kit
  • On-demand fitness videos
  • Nurses are available for free 24 hours a day, 365 days a year.
  • Earn up to $150 in rewards for completing healthy activities like receiving a flu shot, going to the dentist and getting an annual physical.

2023 Part D benefit overview 

Essential (HMO-POS) and FlexSpend (HMO-POS)

Deductible (applies to tiers 3-5)
You pay: $250

1 month/30 day

Preferred retail
Tier 1: $2
Tier 2: $5
Tier 3: $42
Tier 4: $95
Tier 5: 29% cost sharing

Standard retail
Tier 1: $7
Tier 2: $10
Tier 3: $47
Tier 4: $100
Tier 5: 29% cost sharing
 

3 month/100 day

Mail order
Tier 1: $0
Tier 2: $0
Tier 3: $117.50
Tier 4: $285
Tier 5: not applicable

Preferred retail
Tier 1: $2
Tier 2: $10
Tier 3: $117.50
Tier 4: $285
Tier 5: not applicable

Standard retail
Tier 1: $7
Tier 2: $20
Tier 3: $130
Tier 4: $300
Tier 5: not applicable
25% coinsurance

Generic: 5% or $4.15
Brand: 5% or $10.35

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.

View our Medicare disclaimer.
H9096_prevea360.com
Updated: 10/1/2022