SelectHealth Advantage Enhanced (HMO)
H1994 - 007 - 0
(5 / 5)
SelectHealth Advantage Enhanced (HMO) is a Medicare Advantage (Part C) Plan by SelectHealth.
This page features plan details for 2022 SelectHealth Advantage Enhanced (HMO) H1994 – 007 – 0 available in Urban and Northern Utah.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
Locations
SelectHealth Advantage Enhanced (HMO) is offered in the following locations.
Plan Overview
SelectHealth Advantage Enhanced (HMO) offers the following coverage and cost-sharing.
| Insurer: | SelectHealth |
| Health Plan Deductible: | $0 |
| MOOP: | $5,000.00 |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $150.00 annual deductible only applies to drugs on certain tiers.
Ready to sign up for SelectHealth Advantage Enhanced (HMO) ?
Premium Breakdown
SelectHealth Advantage Enhanced (HMO) has a monthly premium of $63.9. 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 |
|---|---|---|---|---|
| $170.10 | $3.10 | $63.90 | $0.00 | $237.10 |
- 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
SelectHealth Advantage Enhanced (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $150.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
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 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $63.90 | $63.90 | $63.90 | $63.90 | $63.90 |
Initial Coverage Phase
After you pay your $150.00 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 $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) * | $10.00 copay | $10.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) * | $30.00 copay | $20.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
SelectHealth Advantage Enhanced (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | 50% coinsurance (limits may apply) (authorization required) |
| Endodontics: | 50% coinsurance (limits may apply) (authorization required) |
| Extractions: | 50% coinsurance (limits may apply) (authorization required) |
| Non-routine services: | 50% coinsurance (limits may apply) (authorization required) |
| Periodontics: | 50% coinsurance (limits may apply) (authorization required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | 50% coinsurance (limits may apply) (authorization required) |
| Restorative services: | 50% coinsurance (limits may apply) (authorization required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) |
| Dental x-ray(s): | $0 copay (limits may apply) |
| Fluoride treatment: | Not covered |
| Oral exam: | $0 copay (limits may apply) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $300 copay (authorization required) |
| Diagnostic tests and procedures: | 0-20% coinsurance (authorization required) |
| Lab services: | $0 copay (authorization required) |
| Outpatient x-rays: | $10 copay (authorization required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $30 copay per visit |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $45 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $30 copay |
| Routine foot care: | $10 copay (limits may apply) |
Ground ambulance
| $225 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (limits may apply) |
| Hearing aids: | $399-1,699 copay |
| Hearing exam: | $30 copay |
Hospital coverage (inpatient)
| $300 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) |
Hospital coverage (outpatient)
| $0-320 copay or 20% coinsurance per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $5,000 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $300 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | $40 copay |
| Outpatient group therapy visit: | $40 copay |
| Outpatient individual therapy visit with a psychiatrist: | $40 copay |
| Outpatient individual therapy visit: | $40 copay |
Optional supplemental benefits
| No |
Preventive care
| $0 copay |
Rehabilitation services
| Occupational therapy visit: | $30 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | $30 copay (authorization required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $160 per day for days 21 through 75 $0 per day for days 76 through 100 (authorization required) |
Transportation
| Not covered |
Vision
| Contact lenses: | $0 copay (limits may apply) (authorization required) |
| Eyeglass frames: | $0 copay (limits may apply) (authorization required) |
| Eyeglass lenses: | $0-65 copay (limits may apply) (authorization required) |
| Eyeglasses (frames and lenses): | Not covered |
| Other: | $0 copay (limits may apply) |
| Routine eye exam: | $0 copay (limits may apply) |
| Upgrades: | $15-45 copay (limits may apply) (authorization required) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
Ready to sign up for SelectHealth Advantage Enhanced (HMO) ?