Medicare Advantage plan options and details


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2022 benefit overview

See our 2022 additional benefits page for more information.

Prevea Essential

$
0
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

$
0
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:

$
0
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.



2021 benefit overview

See our 2021 additional benefits page for more information.

Prevea Essential

$
0
Monthly Premium
  • Part B premium reduction
    (it's like a monthly raise in your Social Security check) $25
  • Hospital copay per day
    In-network: $325 per day for days 1-5 $0 per day for days 6 - discharge
    Out-of-network: $500 per day for days 1-7 $0 per day for days 8 - discharge
  • Primary care doctor's office copay
    In-network: $0 Out-of-network: $30
  • Specialist visit copay
    In-network: $45 Out-of-network: $60
  • Visit (Includes world-wide coverage)
    $90
  • Urgent care visit
    $45
  • Ambulance transportation
    In-network: $250 Out-of-network coinsurance 40%
  • Therapy (physical, occupation, and speech)
    In-network: $40 Out-of-network: $60
  • Maximum out-of-pocket
    In-network: $4,500 In and out combined: $6,000

Prevea Complete

$
226
Monthly Premium
  • Part B premium reduction
    (it's like a monthly raise in your Social Security check) $0
  • Hospital copay per day
    In-network: $325 per day for days 1-5 $0 per day for days 6 - discharge
    Out-of-network: $500 per day for days 1-7 $0 per day for days 8 - discharge
  • Primary care doctor's office copay
    In-network: $0 Out-of-network: $30
  • Specialist visit copay
    In-network: $10 Out-of-network: $60
  • Visit (Includes world-wide coverage)
    $120
  • Urgent care visit
    $10
  • Ambulance transportation
    In-network: $250 Out-of-network coinsurance 40%
  • Therapy (physical, occupation, and speech)
    In-network: $10 Out-of-network: $60
  • Maximum out-of-pocket
    In-network: $2,500 In and out combined: $5,000

Prevea Harmony

$
0
Monthly Premium
  • Part B premium reduction
    (it's like a monthly raise in your Social Security check) $75
  • Hospital copay per day
    In-network: $300 per day for days 1-5 $0 per day for days 6 - discharge
    Out-of-network : $500 per day for days 1-7 $0 per day for days 8 - discharge
  • Primary care doctor's office copay
    In-network: $0 Out-of-network: $30
  • Specialist visit copay
    In-network: $45 Out-of-network: $60
  • Visit (Includes world-wide coverage)
    $90
  • Urgent care visit
    $45
  • Ambulance transportation
    In-network: $250 Out-of-network coinsurance 40%
  • Therapy (physical, occupation, and speech)
    In-network: $40 Out-of-network: $60
  • Maximum out-of-pocket
    In-network: $40 Out-of-network: $60


2021 additional benefit overview

All plans include:

$
0
additional benefits
  • Preventive dental
    • Preventive exams: $0 copay per visit for 2 visits every calendar year
    • Cleanings: $0 copay per visit for 2 visits every calendar year
    • X-Ray: $0 copay per visit for 1 visit every calendar year
  • Comprehensive dental
    • Diagnostic services: $0 copay
    • Periodontics maintenance/emergency services/non-routine services: $45 copay
    • Filings/periodontics/extractions: $95 copay • Crowns/dentures/implants/endodontics/root canals: $595 copay
    • $1,500 every calendar year for dental services
  • In-home and virtual support and companionship
    $0 copay for up to 10 hours of services per month
  • Over-the-counter items
    $60 allowance per quarter
  • Hearing aid
    Plan pays $750 yearly
  • Eyeglasses/contacts
    Plan pays $200 yearly
  • Transportation
    $0 copay for up to 24 one way trips per year
  • Meal benefit
    $0 copay for 14 meals after inpatient discharge
  • Gym and at-home fitness benefit
    Full yearly coverage
  • Nurse line (Prevea After Hours)
    $0
  • Living healthy rewards
    Earn up to $150 per year


2021 Part D benefit overview 

Essential

$
250
Part D Deductible Applies to Tiers 3-5
  • Preferred Retail: Tier 1 Preferred Generic
    $0
  • Preferred Retail: Tier 2 Generic
    $5 copay
  • Preferred Retail: Tier 3 Preferred Brand
    $40 copay
  • Preferred Retail: Tier 4 Non-preferred Drugs
    $90 copay
  • Preferred Retail: Tier 5 Specialty Drugs
    28% coinsurance
  • Preferred Retail: Tier 6 Part D Vaccines (Tdap, Shingrix, and Zostavax)
    $0 copay
  • Standard Retail: Tier 1 Preferred Generic
    $7 copay
  • Standard Retail: Tier 2 Generic
    $12 copay
  • Standard Retail: Tier 3 Preferred Brand
    $47 copay
  • Standard Retail: Tier 4 Non-preferred Drugs
    $100 copay
  • Standard Retail: Tier 5 Specialty Drugs
    28% coinsurance
  • Standard Retail: Tier 6 Part D Vaccines (Tdap, Shingrix, and Zostavax
    $0 copay

Complete

$
0
Part D Deductible Applies to Tiers 3-5
  • Preferred Retail: Tier 1 Preferred Generic
    $0
  • Preferred Retail: Tier 2 Generic
    $0
  • Preferred Retail: Tier 3 Preferred Brand
    $40
  • Preferred Retail: Tier 4 Non-preferred Drugs
    $90
  • Preferred Retail: Tier 5 Specialty Drugs
    33% coinsurance
  • Preferred Retail: Tier 6 Part D Vaccines (Tdap, Shingrix, and Zostavax)
    $0 copay
  • Standard Retail: Tier 1 Preferred Generic
    $7 copay
  • Standard Retail: Tier 2 Generic
    $12 copay
  • Standard Retail: Tier 3 Preferred Brand
    $47 copay
  • Standard Retail: Tier 4 Non-preferred Drugs
    $100 copay
  • Standard Retail: Tier 5 Specialty Drugs
    33% coinsurance
  • Standard Retail: Tier 6 Part D Vaccines (Tdap, Shingrix, and Zostavax
    $0 copay

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: 10/15/2021