Use the guide inside to see the amount you pay for some commonly used benefits and to learn more about some of the many perks that come with your plan.
2023 OSF MedAdvantage
Key Benefits Guide
(877) 933-8480 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 OSFMedAdvantage.org
Medicare Advantage Medicare Supplement Comfort of having an in-network primary care provider to oversee all your care. Generally gives you the flexibility to see any doctor who accepts Original Medicare. Replaces Original Medicare. Supplements Original Medicare. May cover benefits that Original Medicare doesn't. Only covers expenses covered by Original Medicare. No medical underwriting. Medical underwriting (except for guaranteed issue plans). Lower premiums than Medicare Supplement plans. Higher premiums than Medicare Advantage plans. Who pays in what order: health plan, you. Who pays in what order: Original Medicare, health plan, you. Not age- or tobacco-rated. Age- and tobacco-rated. You get more out of Medicare with Medicare Advantage.
Key: This is a summary of commonly used benefits.
+ Also called convenient or walk-in care.
$196 Days 21-100 $0 $2 $15 $47 50% 33% Tier Drugs Covered Through the Coverage Gap OON $5,750 $40 $40 $0 $30 $45 $30 $30 $30 $275 $110 $30 $325 25% $85 Days 1-20;
33% Tier Drugs
Get access to vision services beyond what Original Medicare covers, including a routine vision exam with an in-network provider. Plus, get a $150** allowance for eyewear.
HEARING BENEFIT #**
$400
OON $11,300 $50 $65 $0 $50 $50 $50 $50 $50 $350 $95 $60 25% $600 Days 1-6; $0 Days 7-90 $100 Days 1-20; $200 Days 21-100
available on HMO Classic Rx. Plan Costs Office Visits Diagnostic Services Emergency Services Hospital Services Initial Rx Coverage (for 30-day supply) Plan Type† Network Premium DeductibleMedical Yearly Limit (doesn’t include pharmacy) PCP Visit VisitSpecialist Virtual Visit TherapyPhysical Chiropractic Lab X-Ray CT/MRI Ambulance» Care*Emergency Urgent Care+ HospitalOutpatientCare Inpatient Hospital Care^& (including services received) Skilled Nursing Facility & (noncostodial care based on medical necessity) Rx Deductible Rx Cost by Tier Rx Gap Coverage 2 3 4 5 1 OSF MedAdvantage Core (HMO) Tier $0 $0 $3,900 $0 $40 $0 $10 $20 $15 $40 $40 $295 $110 $0 $275 $300 Days 1-5; $0 Days 6+ $0 Days 1-20; $165 Days 21-100 $0 $2 $15 $47 50% 33% Tier Drugs Covered Through the Coverage Gap Tier 2 $35 $50 $0 $40 $20 20% 20% 20% $295 $110 $0 $375 $350 Days 1-5; $0 Days 6+ $0 Days 1-20; $196 Days 21-100 2 OSF MedAdvantage Open (HMO-POS) Tier $39 $0 $4,750 $0 $10 $0 $10 $20 $10 $35 $35 $295 $110 $0 $275 $250 Days 1-7; $0 Days 8+ $0 Days 1-20; $160 Days 21-100 $0 $2 $15 $47 50% 33% Tier Drugs Covered Through the Coverage Gap Tier 2 $4,750 $35 $50 $0 $40 $20 $25 $60 $60 $295 $110 $0 30% $325 Days 1-6; $0 Days 7+ $0 Days 1-20; $196 Days 21-100 OON $8,950 $50 $60 $0 $60 $50 25% 25% 25% $295 $110 $0 50% $600 Days 1-4; $0 Days 5-90 $100 Days 1-20; $200 Days 21-100 3 OSF Enrich (HMO-POS) IN $150 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 (Tiers$175 3, 4, 5) $2 $15 $47 40% 30% Tier Drugs Covered Through the Coverage Gap OON $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 4 HMO Basic (HMO) IN $0 $0 $6,700 $10 $45 $0 $40 $20 20% 20% $150 $275 $95 $60 20% $300 Days 1-6; $0 Days 7+ $0 Days 1-20;$ 196 Days 21-100 N/A N/A N/A N/A N/A N/A N/A 5 HMO Basic Rx (HMO) IN $33 $0 $6,700 $5 $45 $0 $40 $20 $20 20% $150 $275 $95 $60 20%
Days
Days 7+
» Non-emergency cost-sharing may vary. Contact the plan for details.
$0 $2 $15 $47 50% 33% Tier Drugs Covered Through the Coverage Gap
6 $275 1-7; $0 $0 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier Drugs Covered Through the Coverage Gap
Days 21-100
12 1-8; 1-20; $225
BE FIT
Get fit with a $360/year reimbursement on a variety of fitness activities.
amounts
OTC4ME
COMPANION BENEFIT
Get 10% off on over-the-counter (OTC) products online or by phone.
† Members on POS plans may pay more for preventive care out of network.
Telehealth Benefit Connect with your primary care provider or specialist over the phone or online without the inconvenience of going to the doctor’s office or sitting in a waiting room. Copayment may apply.
Perks and Programs
8 HMO Classic Rx (HMO) IN $0 $0 $8,300 $35 $50 $0 $40 $20 $40 20% $250 $400 $95 $60 25% $300 Days 1-6; $0 Days 7+ $0 Days 1-20;$ 196 Days 21-100 $100 $2 $15 $47 50% 31% Tier Drugs Covered Through the Coverage Gap
VIRTUAL HEALTH COVERAGE
Enrich.
DENTAL COVERAGE
The OON yearly limit includes your combined costs for both in-network and out-of-network care.
Through TruHearing®, you can get one routine hearing exam for a $0 copay and lowered rates on up to two TruHearing hearing aids per year when you see a TruHearing provider.
Days
hospital care and
Days
9 POS Basic (HMO-POS) IN $23 $0 $6,700 $35 $50 $0 $40 $20 $40 $40 $40 $350 $95 $60 25% $450 Days 1-4; $0 Days 5+ 0 Days 1-20; $196 Days 21-100 N/A N/A N/A N/A N/A N/A N/A
IN means in network, and OON means out of network.
^ You pay nothing for days 91 and beyond in network.
Virtual Visits Talk to a board certified doctor or counselor by phone or secure video through hally.com, 24/7.
day.
HMO 40 Rx (HMO) IN $75 $0 $4,700 $10 $40 $0 $40 $20 $15 $10 $150 $275 $110 $40 $275
Gap OON $8,950 $50 $50 $0 $50 $50 $50 $50 $50 $275 $110 $40 $375
7 HMO 20 Rx (HMO) IN $125 $0 $4,000 $20 $40 $0 $40 $20 $10 $0 $5 $275 $110 $25 $275 $250 Days 1-7; $0 Days 8+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier Drugs Covered Through the Coverage Gap
available on
**Not $300 1-6; $0 $0 1-20; $196 21-100
# Not OSF
$0 Days 9+ $0 Days
* Emergency care available worldwide.
OON $11,300 $50 $65 $0 $50 $50 $50 $50 $50 $350 $95 $60 25% $600 Days 1-6; $0 Days 7-90 $100 Days 1-20; $200 Days 21-100
$15 $45 $0 $20 $20 $40 $40 $40 $275 $110 $40 $325
$0
& Dollar amounts listed for inpatient SNF are you pay per
Days
If your fees are more than $360 a year, you pay the difference. If they’re less, we pay you back the amount you paid. Be Fit doesn’t cover fitness trackers or personal equipment.
VISION COVERAGE #
11 POS 30 Rx (HMO-POS) IN $105 $0 $5,500 $350 Days 1-5; $0 Days 6+ $0 Days 1-20; $196 Days 21-100 $2 $15 $47 50% Covered Through the Coverage $375 Days 1-8; $0 Days 9-60; $200 Days 61-90 $200 Days 1-20; Days 21-100
POS 10 Rx (HMO-POS) IN $165 $0 $4,500 $20 $30 $0 $20 $20 $0 $0 $0 $275 $110 $30 $275 $250 Days
10 POS Basic Rx (HMO-POS) IN $53 $0 $6,700 $15 $50 $0 $40 $20 $40 $50 $50 $350 $95 $60 25% $450 Days 1-4; $0 Days 5+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier Drugs Covered Through the Coverage Gap
Get up to 30 hours of in-home support yearly (in one-hour increments).
Get help paying for dental services, like cleanings, X-rays and more, with coverage up to $2,000 a year. (OSF MedAdvantage Enrich has a $1,750 coverage limit.)
Days 8+
Days
Inpatient hospital care: The amount you pay for a stay in an in-network hospital.*
Skilled nursing facility (SNF): What you pay for an approved stay at a SNF.
Emergency care: The amount you pay for emergency care, like a trip to the emergency department.
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
• Tier 2 – Other chosen providers, hospitals and facilities in the counties where OSF MedAdvantage plans are offered.
Medical tier - The cost group a provider, hospital or facility belongs to. Two medical tiers make up the provider network.
• Tier 3 (Preferred Brand).
Helpful Terms
Ambulance: What you pay for an ambulance ride in an emergency.
Drug tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups:
• Tier 4 (Non-Preferred Drug).
Copayment/coinsurance: The set dollar amount or percentage you pay for a doctor’s visit, at the hospital or at the pharmacy. Copayment is a specific dollar amount (like $20), and coinsurance is a percentage (like 20%).
Urgent care: The amount you pay for urgent or convenient care.
*Review the provider directory at OSFMedAdvantage.org for our in-network doctors and hospitals. With an HMO plan, you choose a primary doctor (or PCP) from our broad network. You are not covered out of network unless it’s for emergency or urgent care.
With a POS plan, you still choose an in-network PCP, but you have the freedom to go out of network. You will save money by staying in network, though.
• Tier 2 (Generic).
Medical deductible: What you pay out-of-pocket before your coverage starts.
Generally, the higher the tier, the more you pay for the drug. Some prescriptions require step therapy (for you to try a lower tier first), prior authorization or a limit on the amount you can receive at one time. If your drug isn’t covered, you can ask for an exception. For more information, see the formulary.
Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
• Tier 1 (Preferred Generic).
• Out-of-network coverage – Providers not part of Tier 1 or Tier 2.
Outpatient surgery: What you pay for an outpatient procedure.
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.*
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare. For more information, go to the Perks section.
• Tier 5 (Specialty Tier).
Generally, your costs for services will be the lowest when using Tier 1 providers.
Yearly limit: The limit of how much money you pay for covered medical services, including copayments and coinsurance, each year. It’s also called out-of-pocket maximum.
• Tier 1 – Most OSF HealthCare providers, hospitals and facilities.
Lab: What you pay for lab services, like blood tests.
OSF MedAdvantage is administered by Health Alliance™ Medicare - a Medicare Advantage Organization with a Medicare contract. Enrollment in OSF MedAdvantage depends on contract renewal. Other pharmacies, physicians and providers are available in our network. Health Alliance Medicare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Spanish: ATENCIÓN: Si habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame (800) 965-4022 (TTY 711). Chinese: 注意：如果你講中文，語言協助服務，免費的，都可以給你。呼叫 (800) 965-4022 (TTY 711). Out-of-network/non-contracted providers are under no obligation to treat OSF MedAdvantage members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. MDMBOS23-OSFILNfoldguide-0622 • H1463_23_108816_M