Select Health Medicare NoRx (HMO)
H1994 - 016 - 0
(5 / 5)
Select Health Medicare NoRx (HMO) is a Medicare Advantage (Part C) Plan by Select Health.
This page features plan details for 2024 Select Health Medicare NoRx (HMO) H1994 – 016 – 0 available in Davis, Salt Lake, Utah, and Weber Counties.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Select Health Medicare NoRx (HMO) is offered in the following locations.
Plan Overview
Select Health Medicare NoRx (HMO) offers the following coverage and cost-sharing.
| Insurer: | Select Health |
| Health Plan Deductible: | $0.00 |
| MOOP: | $6,700 In-network |
| Drugs Covered: | No |
Ready to sign up for Select Health Medicare NoRx (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.
Select Health Medicare NoRx (HMO) qualifies for a monthly Medicare Give Back Benefit of $50.00.
| Premium Reduction: | $50.00 |
Premium Breakdown
Select Health Medicare NoRx (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 | $50.00 | $124.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Select Health Medicare NoRx (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $6,700 In-network |
| No |
| In-network | No |
| $40-350 copay or 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $40 copay per visit (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 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 | $0-40 copay or 0-20% coinsurance (Authorization is required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $0-300 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $40 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $299-1,799 copay (There are no limits.) (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 | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| 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 | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Occupational therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| $250 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $40 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | $40 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% 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 (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 | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| $360 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $360 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $15 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $15 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $203 per day for days 21 through 55 $0 per day for days 56 through 100 (Authorization is required.) (Referral is not required.) |
Ready to sign up for Select Health Medicare NoRx (HMO) ?
Table of Contents
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