2018 Plans


Elite D Plan 2018

This plan includes prescription drug coverage.

Monthly Premium

$23.20

Annual Out-of-Pocket Maximum (does not include prescription drugs)

$3,400

Office Visit (Personal physician/specialist)

Primary Care Provider: $0 copay/visit

Specialist: $45 copay/visit

Urgent Care (worldwide)

ProHealth Urgent Care: $0/visit
Participating Urgent Care $30/visit
Non-Participating Urgent Care $60/visit

Emergency (worldwide)

$100 copay

Lab and X-ray

You pay 20%.

Inpatient Hospital Coverage

Days 1-5: $295 copay/day
Days 7 and beyond: $0

Skilled nursing facility (an initial 3-day hospital stay required)

Days 1 - 20: $0
Days 21 - 100: $130 copay/day

Vision

Initial eye exam: $45
Eyewear: $100 for frames and lenses

Hearing

Hearing exam: $15

Hearing Aids: $699-$999 copay/aid
Limit: 1 per ear/year

Outpatient Surgery

Hospital: $250 copay
Ambulatory Surgical Center: $150 copay

Preventive Services

Covered in full

Part D Prescription Drug Coverage

This plan includes Part D coverage

Part D Prescription Drug Copayments

Elite Plan 2018

This plan does not include prescription drug coverage.

Monthly Premium

$0

Annual Out-of-Pocket Maximum (does not include prescription drugs)

$3,400

Office Visit (Personal physician/specialist)

Personal physician: $0 copay/visit
Specialist: $45 copay/visit

Urgent Care (worldwide)

ProHealth Urgent Care: $0 copay/visit
Participating Urgent Care: $30 copay/visit
Non-Participating Urgent Care: $60 copay/visit

Emergency (worldwide)

$100 copay

Lab and X-ray

You pay 20%.

Inpatient Hospital Coverage

Day 1-5: $295/day
Day 7 and beyond: $0

Skilled nursing facility (an initial 3-day hospital stay required)

Days 1 - 20: $0
Days 21 - 100: $130 copay / day

Vision

Initial eye exam: $45
Eyewear: $100 for frames and lenses

Hearing

Hearing exam: $15

Hearing Aids: $699-$999 copay/aid
Limit: 1 per ear/year

Outpatient Surgery

Hospital: $250 copay
Ambulatory Surgical Center: $150 copay

Preventive Services

Covered in full

Part D Prescription Drug Coverage

This plan does not include prescription drug coverage.

Part D Prescription Drug Copayments

No Part D drug coverage. 

Value D Plan 2018

This plan includes prescription drug coverage.

Monthly Premium

$0

Annual Out-of-Pocket Maximum (does not include prescription drugs)

$5,900 for services you receive from in-network providers.

Office Visit (Personal physician/specialist)

Personal physician: $0 copay/visit
Specialist: $50 copay/visit

Urgent Care (worldwide)

ProHealth Urgent Care: $0
Participating Urgent Care: $30 copay per visit
Non-Participating Urgent Care: $60 copay per visit

Emergency (worldwide)

$80 copay

Lab and X-ray

You pay 20%.

Inpatient Hospital Coverage

Days 1-4: $325 copay/day
Days 5 and beyond: $0

Skilled nursing facility (an initial 3-day hospital stay required)

Days 1 - 20: $0
Days 21 - 100: $160 copay/day

Vision

Initial eye exam: $50
Eyewear: $100 for frames and lenses

Hearing

(available through UW Health Audiology)

Hearing exam: $15
Hearing Aids: $699-$999 copay/aid
Limit: 1 per ear/year

Outpatient Surgery

Hospital: $250 copay
Ambulatory Surgical Center: $150 copay

Preventive Services

Covered in full

Part D Prescription Drug Coverage

This plan includes Part D Coverage.

Part D Prescription Drug Copayments


2017 Plans


Elite D Plan 2017

This plan includes prescription drug coverage.

Monthly Premium

$22.50

Annual Out-of-Pocket Maximum (does not include prescription drugs)

$3,400

Office Visit (Personal physician/specialist)

Primary Care: $0 copay/per visit

Specialist: $45 copay/visit

Urgent Care (worldwide)

In-network: $30 copay/visit

Out-of-network: $60 copay/visit

Emergency (worldwide)

$75 copay/visit

Lab and X-ray

You pay 20%.

Inpatient Hospital Coverage

Days 1-5: $295 copay/day

Days 6 and beyond: $0

Skilled nursing facility (an initial 3-day hospital stay required)

Days 1-20: $0

Days 21-100: $130 copay/day

Vision

Exam: $45 copay

Eyewear: $100 for frames, lenses and upgrades

Hearing

Hearing exam: $15 copay

Hearing Aids: $699-$999 copay per aid

Limit: 1 per ear/year

Outpatient Surgery

Hospital: $250 copay

Ambulatory Surgical Center: $150 copay

Preventive Services

Covered in full.

Part D Prescription Drug Coverage

This plan includes Part D coverage.

Part D Prescription Drug Copayments

Elite Plan 2017

This plan does not include prescription drug coverage.

Monthly Premium

$0     

Annual Out-of-Pocket Maximum (does not include prescription drugs)

   $3,400

Office Visit (Personal physician/specialist)

Primary care: $0 copay/per visit

Specialist: $45 copay/visit

Urgent Care (worldwide)

In-network: $30 copay/visit

Out-of-network: $60 copay/visit

Emergency (worldwide)

$75 copay/visit

Lab and X-ray

You pay 20%.

Inpatient Hospital Coverage

Days 1-5: $295 copay/day

Days 6 and beyond: $0

Skilled nursing facility (an initial 3-day hospital stay required)

Days 1-20: $0

Days 21-100: $130 copay/day

Vision

Exam: $45 copay

Eyewear: $100 for frames, lenses and upgrades

Hearing

Hearing exam: $15 copay

Hearing Aids: $699-$999 copay per aid

Limit: 1 per ear/year

Outpatient Surgery

Hospital: $250 copay

Ambulatory Surgical Center: $150 copay

Preventive Services

Covered in full.

Part D Prescription Drug Coverage

This plan does not include Part D coverage.

Part D Prescription Drug Copayments

This plan does not include Part D coverage.

Value D Plan 2017

This plan includes prescription drug coverage.

Monthly Premium

$0

Annual Out-of-Pocket Maximum (does not include prescription drugs)

$5,900

Office Visit (Personal physician/specialist)

Primary Care: $0 copay/per visit

Specialist: $50 copay/visit

Urgent Care (worldwide)

In-network: $30 copay/visit

Out-of-network: $60 copay/visit

Emergency (worldwide)

$75 copay/visit

Lab and X-ray

You pay 20%.

Inpatient Hospital Coverage

Days 1-4: $355 copay/day

Days 5 and beyond: $0

Skilled nursing facility (an initial 3-day hospital stay required)

Days 1-20: $0

Days 21 -100: $135 copay/day

Vision

Exam: $50 copay

Eyewear: $100 for frames, lenses and upgrades

Hearing

Hearing exam: $15 copay

Hearing Aids: $699-$999 copay per aid

Limit: 1 per ear/year

Outpatient Surgery

Hospital: $250 copay

Ambulatory Surgical Center: $150 copay

Preventive Services

Covered in full.

Part D Prescription Drug Coverage

This plan includes Part D coverage.

Part D Prescription Drug Copayments

Out-of-network providers

In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. These are three exceptions:

  1. The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 in the Evidence of Coverage (links to the Evidence of Coverage documents can be found above).
  2. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. If your network provider suggests or recommends care out-of-network, a referral must be obtained in writing, and signed by the plan’s medical director prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider.
  3. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

Using a pharmacy that is out of the network

There are special circumstances when our plan will cover prescriptions from out of network providers/pharmacies; they are as follows:

1. Drugs may be covered for an illness while members are travelling outside of the plan’s service area and where there are no network pharmacies.

2. Part D vaccines administered in a clinic or hospital setting which are considered out of network.

In the event you are unable to use an in network pharmacy and none of the above scenarios would apply; you must have prior authorization (advance approval) from our plan to get prescriptions from an out-of-network pharmacy provider. If you pay out-of-pocket for a prescription and you feel we should cover this expense, please contact us or send the bill to us for payment review. You can find more detailed information regarding how this is done in your Evidence of Coverage in Chapter 7, section 2.1.

Interpreter Services

Interpreter Services Information can be found here. We have interpreter services available to answer questions about our health and drug plan. To get an interpreter, call us at (800) 394‐5566. This is a free service.

Contact Information 

If you have questions or require language assistance, please call Customer Service at (608) 775-8077 or (800) 394-5566. For people who are deaf, hard of hearing, or speech impaired please call TTY/TDD 711 or toll free (800) 877-8973. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. You may also call through a video relay service company of your choice.  Interpreter services are provided free of charge to you. A customer service representative is available to assist you Monday through Friday from 8 a.m. to 8 p.m. From October 1 through February 14 we are also available to assist you on Saturdays and Sundays from 8 a.m. to 8 p.m.

Disclaimers

Senior Preferred is an HMO plan with a Medicare contract. Enrollment in Senior Preferred depends on contract renewal. Medicare Advantage & Part D contracts are reviewed annually by The Centers for Medicare and Medicaid Services to determine renewal status of the plan. You must continue to pay your Medicare Part B premium. The benefit information provided herein is a brief summary, not a comprehensive description of benefits.  Members must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. For more information contact the plan.

Senior Preferred does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

This web page was updated on October 25, 2017.