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OUR 2017 PLAN OPTIONS

If you have questions about Senior Preferred, please contact us at (800) 394-5566. 

Senior Preferred is an HMO Medicare Advantage product. To qualify, you need to be a eligible for Medicare Part A, enrolled in Medicare Part B and a resident of Waukesha county. Our members receive medical care through the ProHealth Senior Preferred network of healthcare providers and facilities except in urgent or emergency care situations out of the service area. To print a 2017 Plan Comparison Guide click here.

Senior Preferred is an HMO Medicare Advantage product. Our members receive medical care through Gundersen Health Plan Senior Preferred's network of healthcare providers and facilities (except in urgent or emergency care situations when a member is out of the service area).

Elite D Plan

This plan includes prescription drug coverage.


Coverage Documents


Monthly Premium

$22.50


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

$3,400


Office Visit 

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 (there is no 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

Learn more here.

Elite Plan

This plan does not include prescription drug coverage.


Coverage Documents


Monthly Premium

$0


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

$3,400


Office Visit 

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 (there is no 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

This plan includes prescription drug coverage.


Coverage Documents


Monthly Premium

$0


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

$5,900


Office Visit 

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 (there is no 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

Learn more here.

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 30, 2016.