Elite Plan 2017
Primary care: $0 copay/per visit
Specialist: $45 copay/visit
In-network: $30 copay/visit
Out-of-network: $60 copay/visit
Days 1-5: $295 copay/day
Days 6 and beyond: $0
Days 1-20: $0
Days 21-100: $130 copay/day
Exam: $45 copay
Eyewear: $100 for frames, lenses and upgrades
Hearing exam: $15 copay
Hearing Aids: $699-$999 copay per aid
Limit: 1 per ear/year
Hospital: $250 copay
Ambulatory Surgical Center: $150 copay
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 traveling 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.
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.
If you have questions or require language assistance, please contact Customer Service.
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 December 11, 2018.