Independent Health's Medicare Family Choice (HMO I-SNP)
Medicare Advantage Health Plan Details
Institutional Special Needs Plans (I-SNP)
Health insurance company offering plan: Independent Health
- Rx
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0-$20 copay
Out-of-network: $0-$50 copay
Out-of-network: $0 copay
Emergency Room
$50 copay
Ambulance Coverage
In-network: $30 copay
Out-of-network: $30 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $0-$50 copay
Out-of-network: $0-$50 copay
Lab services:
In-network: 0%-20% coinsurance
Out-of-network: 0%-20% coinsurance
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $50-$550 copay
Out-of-network: $50-$550 copay
Outpatient x-rays:
In-network: 10% coinsurance
Out-of-network: 10% coinsurance
Hospital Services
Inpatient hospital coverage:
Tier 1
$200 per stayTier 2
$550 per stay
Outpatient hospital coverage:
In-network: $250-$550 copay
Out-of-network: $250-$550 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $0 copay
Out-of-network: $0 copay
Urgent Care Coverage
$50 copay
Skilled Nursing Facility (SNF)
$0 copay
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $0 copay
Out-of-network: $0 copay
Outpatient individual therapy with a psychiatrist:
In-network: $0 copay
Out-of-network: $0 copay
Outpatient group therapy visits:
In-network: $0 copay
Out-of-network: $0 copay
Outpatient individual therapy visit:
In-network: $0 copay
Out-of-network: $0 copay
Dental, Vision, Hearing Benefits
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: $0 copay
Contact Lenses:
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses:
In-network: $0 copay
Out-of-network: $0 copay
Hearing Benefits
Hearing exam:
In-network: $0 copay
Out-of-network: $0 copay
Fitting/evaluation:
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - prescription:
In-network: $0 copay
Out-of-network: $0 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$2.00 copay (30-day supply)
$5.00 copay (90-day supply)
Tier 2: Generic
$10.00 copay (30-day supply)
$25.00 copay (90-day supply)
Tier 3: Preferred Brand
$37.00 copay (30-day supply)
$92.50 copay (90-day supply)
Tier 4: Non-Preferred Drug
40% coinsurance (30-day supply)
40% coinsurance (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Additional Added Benefits
Plan Links
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