|
Monthly premium
The amount you pay each month.
You must continue to pay your Medicare Part B premium.
Low Income Subsidy can help pay for prescription drugs and monthly premiums. Find out more.
|
$0 |
$113 |
|
Part B premium reduction
The amount the plan will pay towards your Part B monthly premium.
|
$6/month |
$6/month |
In-network out-of-pocket maximum
The most you pay each year for Medicare-covered services from in-network providers. |
$6,700 |
$3,850 |
| 2025 Star Rating |
3.5 out of 5 Star Rating (H3832).
English [PDF] | Chinese [PDF] | Ilocano [PDF] | Korean [PDF] | Spanish [PDF] | Vietnamese [PDF]
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|
Provider Directory
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|
| Medical Benefits* |
| |
You Pay |
You Pay |
| Annual deductible |
$0 |
$0 |
| Inpatient hospital care* |
Days 1 to 5:
$320/day
Days 6 to 60:
$50/day
Days 61 to 90:
$0/day
|
Days 1 to 4:
$300/day
Days 5 to 90:
$0/day
Additional Days:
$0/day
|
| Skilled nursing facility* |
Days 1 to 20:
$0/day
Days 21 to 60:
$200/day
Days 61 to 100:
$0/day
|
Days 1 to 20:
$20/day
Days 21 to 40:
$190/day
Days 41 to 100:
$0/day
|
| Outpatient hospital facility and ambulatory surgical center services* |
20% |
20% |
| Primary care provider office visit |
$0 |
$0 |
| Specialty care provider office visit |
$50 |
$30 |
| Annual wellness visit |
$0 |
$0 |
| Ambulance service, includes ground and air |
$250 |
$225 |
| Emergency care |
$100 |
$100 |
| Urgent care |
$50 |
$30 |
| Worldwide coverage for emergency and urgent care services |
10% |
10% |
| Diagnostic tests and procedures, lab services, and outpatient X-rays* |
$0 or 20% depending on the service |
$0 or 20% depending on the service |
| Medicare Part B drugs* |
Up to 20% |
Up to 20% |
| Medicare Part B insulin drugs* |
$35 |
$35 |
| Medical equipment and supplies* |
20% |
20% |
| Supplemental Dental Benefits |
|
Diagnostic and preventive dental services:
- Two oral exams every calendar year
- Two cleanings every calendar year
- One set of bitewing X-rays every calendar year
- One set of full mouth x-rays or panoramic x-ray every 5 calendar years
- Two fluoride treatments every calendar year
|
$0 |
$0 |
|
Comprehensive dental services:
- Four extractions every calendar year
- Two fillings every calendar year
|
$0 |
$0 |
|
Comprehensive dental services:
- One root canal every calendar year
- One crown following a root canal on the same tooth every calendar year
|
Not covered |
$0 |
| Dental Provider Directory |
Dental Provider Directory
English [PDF] | Chinese [PDF] | Ilocano [PDF] | Korean [PDF] | Vietnamese [PDF] |
| Supplemental Vision Benefits |
| |
You Pay |
You Pay |
| Routine eye exam (once a calendar year) |
$10 |
$0 |
| Contact lenses and eyeglasses (frames and lenses) |
$0
Plan pays up to $300 every calendar year |
$0
Plan pays up to $300 every calendar year |
| Supplemental Hearing Benefits |
|
Supplemental Hearing Benefits
|
For more information, visit TruHearing or see our Frequently Asked Questions [PDF].
|
|
Routine hearing exam (one every calendar year)
|
$0
|
$0
|
|
Hearing aids (one aid per ear every calendar year)
|
- Basic aid
$195
- Standard aid
$595
- Advanced aid
$995
- Premium aid
$1,395
|
- Basic aid
$195
- Standard aid
$595
- Advanced aid
$995
- Premium aid
$1,395
|
| Other Supplemental Benefits |
|
Over-the-Counter (OTC) Health Products Allowance
You’ll receive a HMSA Extra Benefits debit card with an allowance for over-the-counter health products. You can purchase covered products at select retail stores or through mail order delivery at HMSAExtra Benefits.com or by calling 1-800-790-6019.
For more information, visit hmsa.com/ExtraBenefits.
|
$0
Plan pays $200 per quarter
|
$0
Plan pays $200 per quarter
|
|
Over-the-Counter (OTC) Health Products Catalog
|
Over-the-Counter (OTC) Health Products Catalog [PDF]
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Fitness - Silver&Fit Healthy Aging and Exercise Program
A membership to a participating fitness center, one home fitness kit per year, Well-Being Coaching sessions and more |
Fitness Center Membership
$0/month for standard fitness center,
$30- $250/month for premium fitness center
Home Fitness Kit
$0
1 Home Fitness Kit per calendar year
Well-Being Coaching
$0
Digital Workout Videos
$0
|
Fitness Center Membership
$0/month for standard fitness center,
$30- $250/month for premium fitness center
Home Fitness Kit
$0
1 Home Fitness Kit per calendar year
Well-Being Coaching
$0
Digital Workout Videos
$0
|
Telehealth services
Includes HMSA’s Online Care. |
$0 |
$0 |
Health education
Learn more |
$0 |
$0 |
Health coaching
Learn more |
$0 |
$0 |
| Drug Benefits |
| |
You Pay |
You Pay |
|
Annual deductible
Low Income Subsidy can help pay for prescription drugs and monthly premiums. Find out more.
|
$380
Does not apply to tier 1 drugs, insulin and most Part D vaccines |
$0
|
Initial coverage stage
Until out-of-pocket drug costs reach $2,000 |
| 30-day supply from retail pharmacies |
|
Tier 1 - Preferred Generic
|
$4.50 |
$4 |
|
Tier 2 - Generic
|
$12 |
$11 |
|
Tier 3 - Preferred Brand
|
$47 |
$45 |
|
Tier 3 - Preferred Brand Insulin
|
$35 |
$35 |
|
Tier 4 - Non-Preferred Drug
|
$100 |
$95 |
|
Tier 5 - Specialty
|
27% |
33% |
|
Tier 5 - Specialty Insulin
|
$35 |
$35 |
| 100-day supply from mail-order pharmacy |
|
Tier 1 - Preferred Generic
|
$4.50 |
$4 |
|
Tier 2 - Generic
|
$12 |
$11 |
|
Tier 3 - Preferred Brand
|
$94 |
$90 |
|
Tier 3 - Preferred Brand Insulin
|
$70 |
$70 |
|
Tier 4 - Non-Preferred Drug
|
$200 |
$190 |
|
Tier 5 - Specialty
|
27% |
33% |
|
Tier 5 - Specialty Insulin
|
$105 |
$105 |
Catastrophic coverage stage
After your yearly out-of-pocket drug costs
reach $2,000 |
$0 |
| Most Part D vaccines |
$0 |
| Pharmacy |
Find a pharmacy |
Prescription Drugs List (Formulary)
See if your prescription drugs are covered and search for lower-cost alternatives. Drug Search Tool. |
|
| Resources and Plan Materials |
| Summary of Benefits |
Summary of Benefits [PDF] |
Summary of Benefits [PDF] |
| Annual Notice of Changes |
Annual Notice of Changes [PDF] |
Annual Notice of Changes [PDF] |
| Evidence of Coverage |
|
|
| Member Resources |
Learn more |
Learn more |
