OSF + Simplete (LOC) + Legacy (ILN)
2022 Key Medicare Advantage Benefits Made for You
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. (800) 965-4022 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 HealthAlliance.org/Medicare
Medicare Advantage vs. Medicare Supplement Get more out of Medicare with Medicare Advantage.
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.
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.
(except for guaranteed issue plans)
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
Outpatient surgery: What you pay for an outpatient procedure.
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%).
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
Drug tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups: • Tier
1 (Preferred Generic). • Tier 2 (Generic). • Tier 3 (Preferred Brand). • Tier 4 (Non-Preferred Drug). • Tier 5 (Specialty Tier). 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.
Emergency care: The amount you pay for emergency care, like a trip to the emergency department. Inpatient hospital care: The amount you pay for a stay in an in-network hospital.* Lab: What you pay for lab services, like blood tests. Medical deductible: What you pay out-of-pocket before your coverage starts.
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium. Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.* Skilled nursing facility (SNF): What you pay for an approved stay at a SNF. Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.* Urgent care: The amount you pay for urgent or convenient care. 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. * Review the provider directory at HealthAlliance.org/Medicare for our in-network doctors and hospitals. With an HMO plan, you choose a primary doctor (or PCP) from our broad network. You’re 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 save money by staying in network, though.
Plan Costs Plan†
Network Premium
1
Simplete 1 (HMO)
Tier 1
2
Simplete 2 (HMO)
Tier 1 Tier 2
3
Simplete 3 (HMO-POS)
4 OSF MedAdvantage Core (HMO)
Tier 1 Tier 2
6
OSF MedAdvantage Open (HMO-POS)
7 OSF Enrich (HMO-POS)
IN OON
$50
$15
$10
$10
$40
$20
20%
$0
$40
$15
$40
$0
$40
$50
$50
$0
$3,900
$0
$40
$3,900
$35
$4,750
$0
$0
$4,000
$0
$25
$0
$40
$15
$28
$0
$4,950
$5
$25
$0
$40
$4,950
$20
$40
$0
$4,950
$5
$25
$4,950
$25
$6,700
$0
$0
$0
$39
$0
OON
8
$10
Chiropractic Lab
Tier 1 Tier 2
$15
Specialist Virtual Physical Visit Visit Therapy
OON
5
Ambulance»
PCP Visit
$48
Emergency Services
X-Ray CT/ MRI
Medical Yearly Limit Deductible (does not include pharmacy)
Tier 1 Tier 2
Diagnostic Services
Office Visits
Initial Rx Coverage
Hospital Services
(for 30-day supply; applies only to Rx plans)
Emergency Urgent Care*** Care+
Outpatient Inpatient Hospital Care^ Hospital Care (including services received)
Skilled Nursing Facility (noncustodial care based on medical necessity)
Rx Deductible
1
2
3
4
$250
$90
$40
$200
$250/Day (1-8), $0/Day (9+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$50
$250
$90
$40
$200
$250/Day (1-8), $0/Day (9+), Non-Medicare covered stays follow Tier 2 benefit
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
20%
$150
$250
$90
$40
20%
$250/Day (1-8), $0/Day (9+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$10
$10
$50
$250
$90
$40
$200
$250/Day (1-8), $0/Day (9+), Non-Medicare covered stays follow Tier 2 benefit
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$20
$25
20%
$150
$250
$90
$40
25%
$250/Day (1-8), $0/Day (9+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$50
$50
$50
30%
30%
$250
$90
$40
50%
$600/Day (1-4), $0/Day (5-90)
$100/Day (1-20), $200/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$0
$10
$20
$15
$40
$40
$295
$90
$0
$275
$300/Day (1-5), $0/Day (6+), Non-Medicare covered stays follow Tier 2 benefit
$0/Day (1-20), $165/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$50
$0
$40
$20
20%
20%
20%
$295
$90
$0
$375
$350/Day (1-5), $0/Day (6+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$0
$10
$0
$10
$20
$10
$35
$35
$295
$90
$0
$275
$250/Day (1-7), $0/Day (8+), Non-Medicare covered stays follow Tier 2 benefit
$0/Day (1-20), $160/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$4,750
$35
$50
$0
$40
$20
$25
$60
$60
$295
$90
$0
30%
$325/Day (1-6), $0/Day (7+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$11,300
$50
$60
$0
$60
$50
25%
25%
25%
$295
$90
$0
50%
$600/Day (1-4), $0/Day (5-90)
$100/Day (1-20), $200/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$0/Day (1-60), $0/Day (Days 61+)
$0/Day (1-20), $0/Day (21-100)
$0/Day (1-60), $0/Day (Days 61-90)
$0/Day (1-20), $0/Day (21-100)
$175 (Tiers 3, 4, 5)
$2
$15
$47
40% 30%
Tier 1 coverage through the gap
$150
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Rx Cost by Tier 5
Rx Gap Coverage
9
HMO 40 RX (HMO)
IN
$75
$0
$4,700
$10
$40
$0
$40
$20
$15
$10
$150
$275
$90
$40
$275
$275/Day (1-7), $0/Day (8+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
10
HMO 20 RX (HMO)
IN
$125
$0
$4,000
$20
$40
$0
$40
$20
$10
$0
$5
$275
$90
$25
$275
$250/Day (1-7), $0/Day (8+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
11
POS 30 RX (HMO-POS)
IN
$105
$0
$5,500
$15
$45
$0
$20
$20
$40
$40
$40
$275
$90
$40
$325
$350/Day (1-5), $0/Day (6+)
$0/Day (1-20), $188/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$11,300
$50
$50
$0
$50
$50
$50
$50
$50
$275
$90
$40
$375
$375/Day (1-8), $0/Day (9-60), $200/Day (61-90)
$200/Day (1-20), $400/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$165
$0
$4,500
$20
$30
$0
$20
$20
$0
$0
$0
$275
$90
$30
$275
$250/Day (1-8), $0/Day (9+)
$0/Day (1-20), $188/Day (21 - 100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
$5,750
$40
$40
$0
$30
$45
$30
$30
$30
$275
$90
$30
$325
25%
$85/Day (1-20), $225/Day (21-100)
$0
$2
$15
$47
50% 33%
Tier 1 coverage through the gap
OON
12
POS 10 RX (HMO-POS)
IN OON
Key: This is a summary of commonly used benefits. IN means in network, and OON means out of network.
† Members on POS plans may pay more for preventive care out of network.
The OON yearly limit includes your combined costs for both in-network and out-of-network care.
*** Emergency care available worldwide.
» Non-emergency cost-sharing may vary. Contact the plan for details.
^ You pay nothing for days 91 and beyond in-network.
+ Also called convenient or walk-in care
# Not available to OSF Enrich members.
Perks and Programs Be Fit
Hearing Benefit#
Virtual Health Coverage
Vision Coverage#
Get fit with a $360/year reimbursement on a variety of fitness activities.
Get one routine hearing exam for a $45 copay when you see a TruHearing® provider and lowered rates on up to two TruHearing hearing aids per year.
Talk to a board certified doctor or counselor by phone or secure video through the Hally® app, 24/7. OSF MedAdvantage members have access through OSF OnCall, get started at OSFOnCall.org/VirtualCare.
Get access to vision services beyond what Original Medicare covers, including a $150 allowance for eyewear.
Dental Coverage Get help paying for dental services, like cleanings, X-rays and more, with coverage up to $1,500 a year. (Some plans may have lower coverage.)
OTC4Me Get a 10% discount code for a wide variety of competitively priced overthe-counter (OTC) products with OTC4Me. You can order online or by phone, and all orders are shipped directly to you. Shipping is free on orders over $25.
OSF + Simplete (LOC) + Legacy (ILN)
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). Health Alliance Medicare is a Medicare Advantage Organization with a Medicare contract. Enrollment in Health Alliance Medicare depends on contract renewal. Out-of-network/non-contracted providers are under no obligation to treat Health Alliance Medicare 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. Other pharmacies/physicians/providers are available within our network. MDMBHA22-LOCOSFILNfoldguide-0621 • H1463_22_98524_M