Key Benefits Guide
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.
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OSFMedAdvantage.org
2023 OSF MedAdvantage
Medicare
Medicare
You get more out of Medicare with Medicare Advantage.
Advantage
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.
Perks and Programs
BE FIT
Get fit with a $360/year reimbursement on a variety of fitness activities
DENTAL COVERAGE
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.)
DIGITAL HEALTH OPTIONS
Get care and navigate your health digitally. OSF OnCall Urgent Care lets you chat, video call or send questions about minor illnesses, 24/7. And with Clare, our chatbot at osfhealthcare.org, you get help finding care. Access all of these digital care options from osfhealthcare.org/member.
HEARING BENEFIT#
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.
VISION COVERAGE#
to vision services beyond what Original Medicare covers. Plus, get a $150 allowance for eyewear.
OTC4ME
Get 10% off on over-the-counter (OTC) products online or by phone.
Get access
Plan Costs Office Visits Diagnostic Services Emergency Services Hospital Services Initial Rx Coverage (for 30-day supply) Plan Type† Network Premium Medical Deductible Yearly Limit (doesn’t include pharmacy) PCP Visit Specialist Visit Virtual Visit Physical Therapy Chiropractic Lab X-Ray CT/MRI Ambulance» Emergency Care*** Urgent Care+ Outpatient Hospital Care Inpatient Hospital Care^& (including services received) Skilled Nursing Facility& (noncustodial care based on medical necessity) Rx Deductible Rx Cost by Tier Rx Gap Coverage 1 2 3 4 5 1 OSF MedAdvantage Core (HMO) Tier 1 $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 1 Drugs Covered Through the Coverage Gap Tier 2 $3,900 $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 1 $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 1 Drugs Covered Through the Coverage Gap $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 21-100Tier 2 $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 21-100OON 3 OSF MedAdvantage Enrich (HMO-POS) IN $150 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $175 (Tiers 3, 4, 5) $2 $15 $47 50% 30% Tier 1 Drugs Covered Through the Coverage Gap OON $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Key: This is a summary of commonly used benefits. IN means in network, and OON means out of network. The OON yearly limit includes your combined costs for both in-network and out-of-network care. † Members on POS plans may pay more for preventive care out of network. » Non-emergency cost-sharing may vary. Contact the plan for details. *** Emergency care available worldwide. + Also called convenient or walk-in care. ^ You pay nothing for days 91 and beyond in network. & Dollar amounts listed for inpatient hospital care and SNF are amounts you pay per day. # Not available on Enrich.
Helpful Terms
Ambulance: What you pay for an ambulance ride in an emergency.
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%).
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.
Medical tier - The cost group a provider, hospital or facility belongs to. Two medical tiers make up the provider network.
• Tier 1 – Most OSF HealthCare providers, hospitals and facilities.
• Tier 2 – Other chosen providers, hospitals and facilities in the counties where OSF MedAdvantage plans are offered.
• Out-of-network coverage – Providers not part of Tier 1 or Tier 2.
Generally, your costs for services will be the lowest when using Tier 1 providers.
Outpatient surgery: What you pay for an outpatient procedure.
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.
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 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.
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. MDMKOS23-foldguide-0622 • H1463_23_108826_M
