Memorial Hermann Advantage HMO Plan

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Memorial Hermann Advantage HMO is a health plan with a Medicare contract available to Medicare-eligible individuals who reside in Harris, Fort Bend or Montgomery counties in Texas.

Benefits of our Medicare Advantage HMO

$45 copay for nonformulary brand-name and generic drugs. Mail-Order $20 copay for formulary generic drugs. Up to a 31- to 90-day supply or 100 unit doses at participating pharmacies. $50 copay for formulary brand-name drugs. Humana Gold Plus H4461-036 (HMO-POS) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. This saves health insurers money, but it also saves health plan members money as well – savings for the insurer can translate to lower premiums, deductibles and copays. In general, PPO networks tend to be broader, including more doctors and hospitals than HMO plans, giving you more choice. You can find your copay amounts in the Copayment/Coinsurance section of your rider. Here's how to find that information online: Log in to your account at bcbsm.com. Hover over My Coverage in the blue bar at the top of the page.

The Memorial Hermann Advantage HMO plan offers the same health coverage benefits as Original Medicare, plus enhanced benefits like:

$0 monthly premium

No referrals needed to see any network specialist
Gain access to our full range of specialists without a referral from your primary care physician.

National/worldwide urgent care and emergency coverage
Travel with confidence knowing that Memorial Hermann AdvantageDark fantasy: artwork and music download for mac download. plan has you covered no matter where you are.

Prescription drug coverage (Part D)
Control drug costs with low copays for generics and name-brands, along with access to convenient mail delivery services.

Dental benefits
Receive coverage for preventative dental services (such as routine dental care, oral exams, cleaning, x-rays) at no cost to you.

Vision and hearing benefits
Get annual hearing and eye exam coverage plus $400 toward hearing aids every year.

Maximum out-of-pocket costs
Limit the annual financial liability of your healthcare costs.

Preventive screenings and services at no additional cost
Avoid major medical issues with no-cost preventive screenings for glaucoma, prostate cancer, breast cancer and more.

Fitness benefits and incentives
Enjoy a range of incentives and benefits including no-cost memberships at participating fitness centers. Learn more >

Access to a vast network of hospitals and physicians
Serving Greater Houston with 17 hospitals, numerous specialty institutes and more than 3,000 physicians.

The plan requires you to use doctors and other health care professionals that participate in the Memorial Hermann Advantage HMO plan’s network. With the exception of emergency situations like ER visits, urgent care stays and renal dialysis services, without authorization, neither Medicare nor Memorial Hermann Advantage HMO will pay for these services.

Kaiser Hmo Copay

See the chart below for some of the costs associated with the Memorial Hermann Advantage HMO plan.

Plan BenefitMemorial Hermann
Advantage HMO
Monthly Plan PremiumYou pay nothing*
Deductible No deductible
Maximum Out-of-Pocket Responsibility (does not include Part D prescription drugs) You pay no more than $3,900 annually.
Inpatient Hospital Coverage You pay $300 per day for days 1 through 5. You pay nothing for days 6 and beyond.
Outpatient Hospital Coverage You pay $300 for each Medicare-covered outpatient hospital facility visit.
Doctor Visits Primary Care Physician Visit: You pay $0 per visit. // Specialist Visit: You pay $50 per visit.
Preventive Care You pay nothing.
Emergency Care You pay $90 per visit.
Urgently Needed Services You pay $35 per visit.
Diagnostic Services/Labs/Imaging You pay nothing for Blood Services (Transfusions).
You pay $75 per test for Non-Radiologic Diagnostic Procedures/Tests.
You pay $200 per test for Diagnostic Radiology Services (MRI, CT, PET). Prior authorization required.
You pay $0 per Lab Service.
You pay $25 per session for Therapeutic Radiology Services (Radiation).
You pay $10 per x-ray for Outpatient X-rays.
Hearing Services Basic hearing and balance exam performed by a primary care doctor: You pay $0.
Exam to diagnose and treat hearing and balance issues: You pay $10.
Annual hearing exam: You pay $50.
Hearing Aid(s) per year: $400 annual benefit to go towards the purchase of hearing aids.
Dental ServicesPreventative dental services (such as routine dental care, oral exams, cleaning, x-rays) are covered at no cost to you.
Comprehensive Services (such as Medicare-covered Benefits, non-routine services, diagnostic services, restorative services endodontics and periodontics): You pay up to $2,150.
Please review the Delta Dental fee schedule for a complete list of fees and services. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage HMO website).
We cover: Medicare-covered dental services limited to surgery of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. Prior Authorization required.
Vision ServicesExam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay $0.
Routine Eye Exam Performed by Optician/Optometrist/Ophthalmologist: You pay $50.
Eyewear per year like Contact Lenses, Eyeglasses (frames and lenses): $200 annual benefit to go towards the purchase of eye-wear and contacts.
Mental Health Services
(including Inpatient)
Inpatient Services: You pay $300 per day for days 1 through 5. You pay nothing for days 6 and beyond. Our plan covers an unlimited number of days for an inpatient hospital stay. Prior Authorization required.
Outpatient Services Outpatient group therapy visit: You pay $40.
Outpatient individual therapy visit: You pay $40. Outpatient individual therapy visit corresponds to total cost for each Medicare-covered individual therapy visit provided by a non-physician.
Skilled Nursing FacilityYou pay $0 for days 1 through 20.
You pay $150 per day for days 21 through 100.
Our plan covers up to 100 days in a skilled nursing facility per 60 day benefit period. Prior Authorization required.
Rehabilitation ServicesCardiac (heart) Rehab Services: You pay $25 per visit.
Pulmonary Services: You pay $25 per visit.
Occupational Therapy Visit: You pay $25 per visit.
Physical Therapy and Speech and Language Therapy Visit: You pay $25 per visit.
AmbulanceYou pay $250 per one-way trip.
TransportationMemorial Hermann Advantage HMO does not offer transportation services.
Medicare Part B & D DrugsFor Part B drugs such as chemotherapy drugs: You pay 20% coinsurance.
Other Part B Drugs: You pay 20% coinsurance.
Foot Care (Podiatry Services)Foot exams and treatment: You pay $25. Routine Foot Care Limitations may apply.
Durable Medicare Equipment/SuppliesYou pay 20% coinsurance. Prior Authorization required for items over $1,000.
Wellness Programs (e.g. Fitness)Silver&Fit® Program: You pay nothing. Memorial Hermann Advantage MHO offers Silver&Fit® club membership, Home Fitness Program, fitness challenges and more.
24 Hour Nurse Line: You pay nothing.
Initial Coverage – Preferred Retail Cost-Sharing (After you pay your deductible, if applicable.) Memorial Hermann
Advantage HMO
Deductible$300 Deductible applies to Tiers 4-5
Initial Coverage Limit$4,020
Tier 1: Preferred Generic$2.00 for One-Month Supply // $4.00 for Two-Month Supply // $4.00 for Three-Month Supply Tier 2: Generic $10.00 for One-Month Supply // $20.00 for Two-Month Supply // $20.00 for Three-Month Supply
Tier 3: Preferred Brand$39.00 for One-Month Supply // $78.00 for Two-Month Supply // $78.00 for Three-Month Supply
Tier 4: Non-Preferred Brand$92.00 for One-Month Supply // $184.00 for Two-Month Supply // $184.00 for Three-Month Supply
Tier 5: Specialty Tier Drugs27% for One-Month Supply // Not available for Two-Month Supply // Not available for Three-Month Supply
Initial Coverage – Standard Retail Cost-Sharing (After you pay your deductible, if applicable.) Memorial Hermann
Advantage HMO
Tier 1: Preferred Generic$10.00 for One-Month Supply // $20.00 for Two-Month Supply // $20.00 for Three-Month Supply
Tier 2: Generic$18.00 for One-Month Supply // $36.00 for Two-Month Supply // $36.00 for Three-Month Supply
Tier 3: Preferred Brand$47.00 for One-Month Supply // $94.00 for Two-Month Supply // $94.00 for Three-Month Supply
Tier 4: Non-Preferred Brand$100.00 for One-Month Supply // $200.00 for Two-Month Supply // $200.00 for Three-Month Supply
Tier 5: Specialty Tier Drugs27% for One-Month Supply // Not available for Two-Month Supply // Not available for Three-Month Supply
Mail Order Availability
TierOne-Month SupplyTwo-Month SupplyThree-Month Supply
Tier 1 (Preferred Generic) $2.00 $0 $0
Tier 2 (Generic)$10.00$20.00$20.00
Tier 3 (Preferred Brand)$39.00$78.00$78.00
Tier 4 (Non-Preferred Brand)$92.00$184.00$184.00
Tier 5 (Specialty Tier Drugs)27%Not availableNot available

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.
Coverage GapMost Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020. After you enter the coverage gap, you pay 25% of the price for brand name drugs, plus a portion of the dispensing fee and 25% of the price for generic drugs. Not everyone will enter the coverage gap.
Catastrophic Coverage RxAfter your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of: 5% of the cost, or $3.60 copay for a generic or preferred multi-source drug (including brand drugs treated as generic) and a $8.95 copay for all other drugs.

What to Consider Before Enrolling in a Memorial Hermann Advantage HMO Plan

  • You cannot enroll in a Medicare Advantage plan if you are not already enrolled in Medicare Part A and Part B. To enroll in original Medicare, visit the Social Security Administration’s website, medicare.gov. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website.)
  • In order to be eligible for a Memorial Hermann Advantage HMO plan, you must live within the Harris, Fort Bend or Montgomery counties in Texas.
  • If your current doctor does not participate in the Memorial Hermann Advantage HMO plan, you can talk to an authorized plan representative at (866) 350-2715 (TTY 711) to learn about other providers. You can also view a list of Memorial Hermann Advantage HMO providers, by clicking on the Memorial Hermann Advantage HMO Provider Directory.

*You must continue to pay your Medicare Part B premium.

List Of Hmos In California

This information is not a complete description of benefits. Call (855) 645-8448 TTY 711 for more information.

Blue Care Network Hmo Copay

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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