Independent Health's Medicare Family Choice (HMO I-SNP)
Health Insurance Company: Independent Health
Medicare Advantage Plan Details
Institutional Special Needs Plans (I-SNP)
- Rx
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Emergency Room
$50 copay per visit (always covered)
Ambulance Coverage
$30 copay
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: $0 copay
Medicare-covered lab services: 0-20% coinsurance
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): 10% coinsurance
Medicare-covered x-ray services: 10% coinsurance
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: 10% coinsurance per visit
Hospitalization Coverage
Inpatient hospital-acute:
$150 per stay
Inpatient hospital psychiatric:
$150 per day for days 1 through 5
$0 per day for days 6 through 90
Rehabilitation Coverage
Occupational therapy services:
$0 copay
Physical therapy and speech and language therapy services:
$0 copay
Urgent Care Coverage
$0 copay
Skilled Nursing Facility (SNF)
$0 copay
Mental Health Coverage
Medicare-covered individual sessions: $0 copay
Medicare-covered group sessions: $0 copay
Dental, Vision, Hearing Benefits
Vision Benefits
Eye exams:
Routine eye exams: $0 copay
Eyewear:
Contact Lenses: $0 copay
Eyeglasses: $0 copay
Hearing Benefits
Hearing exams:
Routine hearing exams: $0 copay
Hearing aids:
Hearing aids (all types): $0 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$3.00 copay (30-day supply)
$7.50 copay (90-day supply)
Tier 2: Generic
$13.00 copay (30-day supply)
$32.50 copay (90-day supply)
Tier 3: Preferred Brand
19% coinsurance (30-day supply)
19% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
37% coinsurance (30-day supply)
37% coinsurance (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
More Additional Benefits
Plan Links
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