2022 Summit Health Standard + Rx (HMO-POS)

Summit Health Standard + Rx (HMO-POS) H2765-003 is a 2022 Medicare Advantage Plan or Part-C by Summit Health Plan, Inc available to residents in Oregon. This plan includes additional prescription drug (Part-D) coverage. The Summit Health Standard + Rx (HMO-POS) has a monthly premium of $99.00 and has an in-network maximum out-of-pocket limit of $5,100 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,100 out-of-pocket. This can be a extremely nice safety net.

Summit Health Standard + Rx (HMO-POS) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

Summit Health Plan, Inc works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Summit Health Standard + Rx (HMO-POS) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Summit Health Plan, Inc and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Summit Health Plan, Inc except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Summit Health Plan, Inc Medicare Advantage Plan Costs

Summit Health Standard + Rx (HMO-POS) Part-C Premium

Summit Health Plan, Inc charges a $25.40 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H2765-003 Part-D Deductible and Premium

Summit Health Standard + Rx (HMO-POS) has a monthly drug premium of $73.60 and a $200.00 drug deductible. This Summit Health Plan, Inc plan offers a $73.60 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Summit Health Plan, Inc above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $73.60 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Summit Health Plan, Inc Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Summit Health Plan, Inc plan does not offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Summit Health Standard + Rx (HMO-POS) medicare insurance offers a $33.10 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $43.20 for 75% low income subsidy $53.40 for 50% and $63.50 for 25%.

H2765-003 Formulary or Drug Coverage

Summit Health Standard + Rx (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. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Summit Health Standard + Rx (HMO-POS) H2765-003 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	NA	$4
Tier 2	NA	$10
Tier 3	NA	$45
Tier 4	NA	$100
Tier 5	NA	24%
Tier 6	NA	29%
Tier 7	NA	$0

*Initial Coverage Phase and 30 day supply

2021 Summit Health Standard + Rx (HMO-POS) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	$0 copay
Diagnostic services	$0 copay (Out-of-Network)
Endodontics	$0 copay (Out-of-Network)
Endodontics	$0 copay
Extractions	$0 copay (Out-of-Network)
Extractions	$0 copay
Non-routine services	$0 copay (Out-of-Network)
Non-routine services	$0 copay
Periodontics	$0 copay
Periodontics	$0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay
Restorative services	$0 copay
Restorative services	$0 copay (Out-of-Network)

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	50% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	20% coinsurance
Diagnostic tests and procedures	50% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$7 copay
Lab services	$7 copay
Lab services	50% coinsurance (Out-of-Network)
Outpatient x-rays	20% coinsurance
Outpatient x-rays	50% coinsurance (Out-of-Network)

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Doctor Visits

Primary	50% coinsurance per visit (Out-of-Network)
Primary	$10 copay per visit
Specialist	50% coinsurance per visit (Out-of-Network)
Specialist	$35 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$50 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	50% coinsurance (Out-of-Network)
Foot exams and treatment	$35 copay
Routine foot care	Not covered

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Ground Ambulance

$300 copay
$300 copay (Out-of-Network)

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Hearing

Fitting/evaluation	Not covered
Hearing aids	$699-999 copay
Hearing exam	$35 copay
Hearing exam	50% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

50% per stay (Out-of-Network)
$370 per day for days 1 through 5 $0 per day for days 6 through 90

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Diabetes supplies	50% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	50% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	50% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	50% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance
Other Part B drugs	50% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	50% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$370 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit	$35 copay
Outpatient group therapy visit	50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$35 copay
Outpatient group therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$35 copay
Outpatient individual therapy visit	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$35 copay

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MOOP

$8,000 In and Out-of-network $6,250 In-network $8,000 Out-of-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

$370 copay per visit
50% coinsurance per visit (Out-of-Network)

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Package #1

Deductible
Monthly Premium	$5.00

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Preventive Care

$0 copay
50% coinsurance (Out-of-Network)

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Preventive Dental

Cleaning	$0 copay (Out-of-Network)
Cleaning	$0 copay
Dental x-ray(s)	$0 copay (Out-of-Network)
Dental x-ray(s)	$0 copay
Fluoride treatment	$0 copay
Fluoride treatment	$0 copay (Out-of-Network)
Oral exam	$0 copay (Out-of-Network)
Oral exam	$0 copay

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Rehabilitation Services

Occupational therapy visit	$35 copay
Occupational therapy visit	50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$35 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $165 per day for days 21 through 100
50% per stay (Out-of-Network)

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Transportation

Not covered

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Vision

Contact lenses	$0 copay
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	$0 copay
Upgrades	$0 copay

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Summit Health Standard + Rx (HMO-POS)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.