Saint Alphonsus Health Plan Cash Back No Premium 2 (HMO)
H6910 - 004 - 0
(3.5 / 5)
Saint Alphonsus Health Plan Cash Back No Premium 2 (HMO) is a Medicare Advantage (Part C) Plan by Saint Alphonsus Health Plan.
This page features plan details for 2024 Saint Alphonsus Health Plan Cash Back No Premium 2 (HMO) H6910 – 004 – 0 available in Select Counties in Idaho.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Saint Alphonsus Health Plan Cash Back No Premium 2 (HMO) is offered in the following locations.
Plan Overview
Saint Alphonsus Health Plan Cash Back No Premium 2 (HMO) offers the following coverage and cost-sharing.
| Insurer: | Saint Alphonsus Health Plan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,900 In-network |
| Drugs Covered: | No |
Ready to sign up for Saint Alphonsus Health Plan Cash Back No Premium 2 (HMO) ?
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.
Saint Alphonsus Health Plan Cash Back No Premium 2 (HMO) qualifies for a monthly Medicare Give Back Benefit of $100.00.
| Premium Reduction: | $100.00 |
Premium Breakdown
Saint Alphonsus Health Plan Cash Back No Premium 2 (HMO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $100.00 | $74.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Saint Alphonsus Health Plan Cash Back No Premium 2 (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $3,900 In-network |
| Yes |
| In-network | No |
| $0-225 copay per visit (Authorization is not required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $25 copay per visit (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $30 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $10 copay (Authorization is required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $100 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient x-rays | $10 copay (Authorization is not required.) (Referral is not required.) |
| Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $399-699 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Restorative services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Endodontics | 70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Periodontics | 70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Extractions | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $20 copay (Authorization is not required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $20 copay (Authorization is not required.) (Referral is not required.) |
| $225 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| $250 per day for days 1 through 4 $0 per day for days 5 through 90 (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $250 per day for days 1 through 4 $0 per day for days 5 through 90 (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $20 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $20 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $20 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $20 copay (Authorization is not required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $203 per day for days 21 through 56 $0 per day for days 57 through 100 (Authorization is not required.) (Referral is not required.) |
| Monthly Premium | $21.00 |
| Deductible | nan |
| Monthly Premium | $41.00 |
| Deductible | nan |
Optional Benefits
Package #1
| Comprehensive dental: | Monthly Premium: | $21.00 |
| Comprehensive dental: | Deductible: | N/A |
Package #2
| Comprehensive dental: | Monthly Premium: | $41.00 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for Saint Alphonsus Health Plan Cash Back No Premium 2 (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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