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Primewell Classic (HMO-POS)

H7163 - 002 - 0

(4 / 5)

Primewell Classic (HMO-POS) is a Medicare Advantage Plan by Primewell Health Services.

This page features plan details for 2025 Primewell Classic (HMO-POS) H7163 – 002 – 0.

IMPORTANT: This page features the 2025 version of this plan. See the 2025 version using the link below:

2025 Primewell Classic (HMO-POS) H7163 - 002 - 0

Locations

Primewell Classic (HMO-POS) is offered in the following locations.

Click to see more locations

Plan Overview

Primewell Classic (HMO-POS) offers the following coverage and cost-sharing.

Insurer:	Primewell Health Services
Health Plan Deductible:	$500 Out-of-network
MOOP:	$4,400 In-network
Drugs Covered:	Yes

Ready to sign up for Primewell Classic (HMO-POS) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.

Primewell Classic (HMO-POS) qualifies for a monthly Medicare Give Back Benefit of $0.60.

Premium Reduction:

$0.60

Premium Breakdown

Primewell Classic (HMO-POS) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$0.00	$0.00	$0.60	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Primewell Classic (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$0.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$8.00 Copay		$8.00 Copay
2) Generic	$12.00 Copay	$16.00 Copay	$12.00 Copay	$16.00 Copay
3) Preferred Brand	$45.00 Copay	$47.00 Copay	$45.00 Copay	$47.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance

60 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$16.00 Copay		$16.00 Copay
2) Generic	$24.00 Copay	$32.00 Copay	$24.00 Copay	$32.00 Copay
3) Preferred Brand	$90.00 Copay	$94.00 Copay	$90.00 Copay	$94.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$24.00 Copay		$24.00 Copay
2) Generic	$36.00 Copay	$48.00 Copay	$36.00 Copay	$48.00 Copay
3) Preferred Brand	$135.00 Copay	$141.00 Copay	$135.00 Copay	$141.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Primewell Classic (HMO-POS) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: Yes, contact plan for further details

Comprehensive Dental

Adjunctive General Services
- In-Network: No Coins – 0.00 Copay (Limits Apply)
- Out-of-Network: No Coins – No Copay (Limits Apply)
Endodontics
- In-Network: No Coins – 0.00 Copay (Limits Apply)
- Out-of-Network: No Coins – No Copay (Limits Apply)
Implant Services
- In-Network: No Coins – 0.00 Copay (Limits Apply)
- Out-of-Network: No Coins – No Copay (Limits Apply)
Oral and Maxillofacial Surgery
- In-Network: No Coins – 0.00 Copay (Limits Apply)
- Out-of-Network: No Coins – No Copay (Limits Apply)
Periodontics
- In-Network: No Coins – 0.00 Copay (Limits Apply)
- Out-of-Network: No Coins – No Copay (Limits Apply)
Prosthodontics, fixed
- In-Network: No Coins – 0.00 Copay (Limits Apply)
- Out-of-Network: No Coins – No Copay (Limits Apply)
Prosthodontics, removable
- In-Network: No Coins – 0.00 Copay (Limits Apply)
- Out-of-Network: No Coins – No Copay (Limits Apply)
Restorative Services
- In-Network: No Coins – 0.00 Copay (Limits Apply)
- Out-of-Network: No Coins – No Copay (Limits Apply)

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – 0.00 Copay
- Out-of-Network: No Coins – No Copay
Fluoride Treatment
- In-Network: No Coins – 0.00 Copay
- Out-of-Network: No Coins – No Copay
Oral Exams
- In-Network: No Coins – 0.00 Copay
- Out-of-Network: No Coins – No Copay
Other Diagnostic Dental Services
- In-Network: No Coins – 0.00 Copay
- Out-of-Network: No Coins – No Copay
Prophylaxis (cleaning)
- In-Network: No Coins – 0.00 Copay
- Out-of-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI)
- In-Network: $0-200 copay (Authorization Required)
Diagnostic tests and procedures
- In-Network: $0-30 copay (Authorization Required)
- Out-of-Network: 50% coinsurance (Authorization Required)
Diagnostic radiology services (e.g., MRI)
- Out-of-Network: 50% coinsurance (Authorization Required)
Lab services
- In-Network: $0 copay (Authorization Required)
- Out-of-Network: 50% coinsurance (Authorization Required)
Outpatient x-rays
- In-Network: 0-20% coinsurance (Authorization Required)
- Out-of-Network: 50% coinsurance (Authorization Required)

Doctor visits

Primary
- Out-of-Network: 50% coinsurance per visit
Specialist
- Out-of-Network: 50% coinsurance per visit
- In-Network: $30 copay per visit
Primary
- In-Network: $0 copay

Emergency care/Urgent care

Emergency
- $125 copay per visit (always covered)
Urgent care
- $40 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- Out-of-Network: 50% coinsurance
Routine foot care
- Not covered
Foot exams and treatment
- In-Network: $30 copay

Ground ambulance

- Out-of-Network: $250 copay
- In-Network: $250 copay

Health plan deductible

- $500 Out-of-network

Hearing

Fitting/evaluation
- In-Network: $0 copay (Limits Apply)
Hearing aids
- In-Network: $0 copay (Limits Apply)
Medicare-Covered Hearing Exam
- In-Network: $0 copay
Hearing aids OTC
- In-Network: $0 copay
Medicare-Covered Hearing Exam
- Out-of-Network: 50% coinsurance
Fitting/evaluation
- Out-of-Network: $0 copay (Limits Apply)
Hearing aids
- Out-of-Network: $0 copay (Limits Apply)

Inpatient hospital coverage

- In-Network: $245 per day for days 1 through 10
  $0 per day for days 11 through 90 (Authorization Required)
- Out-of-Network: 50% per stay (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $4,400 In-network

Medical equipment/supplies

Diabetes supplies
- In-Network: $0 copay (Authorization Required)
- Out-of-Network: 50% coinsurance per item (Authorization Required)
Durable medical equipment (e.g., wheelchairs, oxygen)
- Out-of-Network: 50% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- Out-of-Network: 50% coinsurance per item (Authorization Required)
Durable medical equipment (e.g., wheelchairs, oxygen)
- In-Network: 20% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- In-Network: 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

Chemotherapy
- Out-of-Network: $35 copay or 0-50% coinsurance (Authorization Required)
Other Part B drugs
- Out-of-Network: $35 copay or 0-50% coinsurance (Authorization Required)
Chemotherapy
- In-Network: 0-20% coinsurance (Authorization Required)
Other Part B drugs
- In-Network: 0-20% coinsurance (Authorization Required)

Mental health services

Inpatient hospital – psychiatric
- In-Network: $225 per day for days 1 through 8
  $0 per day for days 9 through 90 (Authorization Required)
Outpatient individual therapy visit
- In-Network: $40 copay (Authorization Required)
Outpatient individual therapy visit with a psychiatrist
- Out-of-Network: 50% coinsurance (Authorization Required)
Inpatient hospital – psychiatric
- Out-of-Network: 50% per stay (Authorization Required)
Outpatient group therapy visit with a psychiatrist
- In-Network: $40 copay (Authorization Required)
- Out-of-Network: 50% coinsurance (Authorization Required)
Outpatient group therapy visit
- In-Network: $40 copay (Authorization Required)
- Out-of-Network: 50% coinsurance (Authorization Required)
Outpatient individual therapy visit
- Out-of-Network: 50% coinsurance (Authorization Required)
Outpatient individual therapy visit with a psychiatrist
- In-Network: $40 copay (Authorization Required)

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- Out-of-Network: 50% coinsurance per visit (Authorization Required)
- In-Network: $0-350 copay per visit (Authorization Required)

Preventive care

- In-Network: $0 copay
- Out-of-Network: 50% coinsurance

Rehabilitation services

Physical therapy and speech and language therapy visit
- Out-of-Network: 50% coinsurance (Authorization Required)
Occupational therapy visit
- In-Network: $35 copay (Authorization Required)
Physical therapy and speech and language therapy visit
- In-Network: $35 copay (Authorization Required)
Occupational therapy visit
- Out-of-Network: 50% coinsurance (Authorization Required)

Skilled Nursing Facility

- Out-of-Network: 50% per stay (Authorization Required)
- In-Network: $0 per day for days 1 through 20
  $165 per day for days 21 through 100 (Authorization Required)

Transportation

- Not covered

Vision

Contact lenses
- Out-of-Network: $0 copay (Limits Apply)
Eyeglass frames
- Out-of-Network: $0 copay (Limits Apply)
Eyeglasses (frames and lenses)
- In-Network: $0 copay (Limits Apply)
- Out-of-Network: $0 copay (Limits Apply)
Other
- Not covered
Routine eye exam
- Out-of-Network: 50% coinsurance (Limits Apply)
Contact lenses
- In-Network: $0 copay (Limits Apply)
Eyeglass lenses
- In-Network: $0 copay (Limits Apply)
Upgrades
- In-Network: $0 copay (Limits Apply)
Eyeglass frames
- In-Network: $0 copay (Limits Apply)
Eyeglass lenses
- Out-of-Network: $0 copay (Limits Apply)
Routine eye exam
- In-Network: $0 copay (Limits Apply)
Upgrades
- Out-of-Network: $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

- Covered