Medicare Advantage plans in Indiana provide Seniors with an alternative to original Medicare that typically includes prescription drug benefits. Private insurers offer these types of plans (MA and Part C) throughout all counties in the state. Although the cost of coverage can vary, typically, rates are less than Medigap Supplement plans. Also, additional benefits are often available, including dental, vision, hearing, and fitness club and gym membership discounts. Health and wellness coverage is also often included, and customized plans are offered to provide treatment for special conditions. Generally, there is also less paperwork with these types of plans.

Hoosier State MA plans can not decline applicants for poor health, pre-existing conditions, or age, during an Open Enrollment period (October 15th- December 7th) or when first eligible for Medicare benefits. Filing claims is quite easy and often paperless. Denial of services and claims can be appealed. Applicants that have not reached age 65 but are on Medicare because of a disability, can obtain an Advantage plan without being denied.

Advantage plans (Part C) must abide by the rules and regulations of Medicare. The policy rates, out-of-pocket expenses, deductibles, copays, coinsurance, and drug formulary lists can differ. Many plans may not require a referral to see a specialist, while other plans will have more stringent guidelines. The four main types of  plans are Special Needs Plans (SNP), Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Private Fee-For-Service (PFFS).

Also available are PSO (Preferred Sponsored Organizations), which are managed care plans with a provider network, and MSAs (Medical Savings Accounts) that combine a savings account with a high-deductible policy. Religious Fraternal Benefit Society plans is a managed care contract formed by recognized fraternal or religious organizations.

MAP plans also provide the protection for beneficiaries. Covered protections include:

Grievance and appeal procedure

Physicians must  be permitted to inform all treatment options

If requirements are met, contract must be guaranteed to be issued

24/7 care

Access to specialists

Paid emergency coverage if symptoms indicate immediate treatment

You also must reside in the service area (county) of the plan you apply for. If a portion of the year is spent in another state, it’s important to determine if the plan’s service area provides network coverage in that state. It is possible that if you move outside of the state, the current Indiana MA plan may not be available. Changing to a different plan is typically possible during an Open Enrollment period. Although medical underwriting may not be required, the new plan’s benefits, costs, and service area may be different than the current plan. A Supplement plan is not needed when an MA plan is purchased.

Counties with most available MA plans:

47 – Hamilton County

47 – Hancock County

47 – Marion County

46 – Howard County

46 – Madison County

45 – Allen County

45 – Johnson County

43 – Hendricks County

42 – Boone County

41 – Fountain County

41 – St. Joseph County

41 – Warren County

Counties with least available MA plans:

22 – Crawford County

22 – Ripley County

23 – Washington County

23 – Sullivan County

23 – Pulaski County

23 – Washington County

24 – Dearborn County

24 – Decatur County

24 – Greene County

24 – Blackford County

24 – Scott County

24 – Jefferson County

24 – Dubois County

24 – Martin County

24 – Ohio County

24 – Orange County

24 – Perry County

25 – Clark County

25 – Floyd County

25 – Harrison County

25 – Jasper County

Indiana Medicare Advantage Plans Without Prescription Drug Coverage

AARP Medicare Advantage Patriot – PPO with $0 monthly premium and $5,500 maximum out-of-pocket expenses. 4.0 summary Star Rating with $10 and $40 office visit copays and $30-$40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $30, $0, and $30 copays respectively. Inpatient hospital visits are subject to a $350 copay for days 1-5, and the outpatient hospital copay is $0-$370. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $15 and $25.

 

Aetna Medicare Eagle – PPO with $0 monthly premium and $5,900 maximum out-of-pocket expenses. 4.0 summary Star Rating with $0 and $35 office visit copays and $45 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$75, $0, and $20 copays respectively. Inpatient hospital visits are subject to a $290 copay for days 1-7, and the outpatient hospital copay is $0-$400. The ground ambulance copay is $320, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

 

Health Alliance Medicare HMO Basic – HMO with $0 monthly premium and $6,700 maximum out-of-pocket expenses. 4.0 summary Star Rating with $25 and $50 office visit copays and $65 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to 20%, 0%-20%, and 20% copays respectively. Inpatient hospital visits are subject to a $300 copay for days 1-6, and the outpatient hospital copay is 20%. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

 

Health Alliance Medicare POS Basic – HMO-POS with $23 monthly premium and $6,700 maximum out-of-pocket expenses. 4.0 summary Star Rating with $35 and $50 office visit copays and $65 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $40, $0-$40, and $40 copays respectively. Inpatient hospital visits are subject to a $450 copay for days 1-4, and the outpatient hospital copay is 25%. The ground ambulance copay is $350, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

 

Humana Honor – PPO with $0 monthly premium and $6,700 maximum out-of-pocket expenses. 4.0 summary Star Rating with $15 and $45 office visit copays and $15-$45 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$105, $0-$35, and $15-$110 copays respectively. Inpatient hospital visits are subject to a $350 copay for days 1-5, and the outpatient hospital copay is $45-$325. The ground ambulance copay is $270, and rehabilitation therapy visit copays are $20-$40. Mental health outpatient group and individual therapy visit copays are $40.

 

HumanaChoice – Regional PPO with $0 monthly premium and $6,200 maximum out-of-pocket expenses. 3.5 summary Star Rating with $10 and $35 office visit copays and $10-$35 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$105, $0-$40, and $10-$95 copays respectively. Inpatient hospital visits are subject to a $295 copay for days 1-6, and the outpatient hospital copay is $45-$295. The ground ambulance copay is $270, and rehabilitation therapy visit copays are $20-$40. Mental health outpatient group and individual therapy visit copays are $40.

 

IU Health Plans Medicare Select – HMO with $0 monthly premium and $5,000 maximum out-of-pocket expenses. 4.5 summary Star Rating with $0 and $40 office visit copays and $65 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to 20%, $10, and $25 copays respectively. Inpatient hospital visits are subject to a $335 copay for days 1-6, and the outpatient hospital copay is $300. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

 

Reid Health Alliance Medicare – HMO with $0 monthly premium and $6,700 maximum out-of-pocket expenses. 4.0 summary Star Rating with $20 and $50 office visit copays and $45 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $10, $0-$10, and 20% copays respectively. Inpatient hospital visits are subject to a $300 copay for days 1-6, and the outpatient hospital copay is $345. The ground ambulance copay is $300, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

Note: Medicare Supplement plans in Indiana also do not cover prescription drugs and require a separate Part D plan.

 

Indiana Medicare Advantage Rates

 

Indiana Medicare Advantage Plans With Prescription Drug Coverage

AARP Medicare Advantage Profile – HMO-POS with $0 monthly premium, $210 deductible, and $4,500 maximum out-of-pocket expenses. 4.5 summary Star Rating with $5 and $40 office visit copays and $30-$40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $30, $0, and $25 copays respectively. Inpatient hospital visits are subject to a $370 copay for days 1-5, and the outpatient hospital copay is $0-$370. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $15 and $25.

30-day preferred pharmacy copays are $3 (Tier 1), $12 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 29% (Tier 5). 90-day preferred pharmacy copays are $9 (Tier 1), $36 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

AARP Medicare Advantage Focus – PPO with $0 monthly premium, $0 deductible, and $3,900 maximum out-of-pocket expenses. 4.0 summary Star Rating with $0 and $30 office visit copays and $30-$40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $30, $0, and $25 copays respectively. Inpatient hospital visits are subject to a $370 copay for days 1-5, and the outpatient hospital copay is $0-$370. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $30. Mental health outpatient group and individual therapy visit copays are $15 and $25.

30-day preferred pharmacy copays are $2 (Tier 1), $8 (Tier 2), $45 (Tier 3), $95 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $9 (Tier 1), $36 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

AARP Medicare Advantage Choice Plan 1 – PPO with $22 monthly premium, $185 deductible, and $5,200 maximum out-of-pocket expenses. 4.0 summary Star Rating with $0 and $25 office visit copays and $30-$40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $30, $0, and $25 copays respectively. Inpatient hospital visits are subject to a $370 copay for days 1-5, and the outpatient hospital copay is $0-$350. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $35. Mental health outpatient group and individual therapy visit copays are $15 and $25.

30-day preferred pharmacy copays are $3 (Tier 1), $10 (Tier 2), $45 (Tier 3), $95 (Tier 4), and 29% (Tier 5). 90-day preferred pharmacy copays are $9 (Tier 1), $30 (Tier 2), $135 (Tier 3), $285 (Tier 4), and n/a (Tier 5).

 

AARP Medicare Advantage Choice Plan 2 – PPO with $0 monthly premium, $185 deductible, and $5,500 maximum out-of-pocket expenses. 4.0 summary Star Rating with $0 and $25 office visit copays and $30-$40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $30, $0, and $30 copays respectively. Inpatient hospital visits are subject to a $390 copay for days 1-5, and the outpatient hospital copay is $0-$370. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $15 and $30.

30-day preferred pharmacy copays are $3 (Tier 1), $10 (Tier 2), $45 (Tier 3), $95 (Tier 4), and 29% (Tier 5). 90-day preferred pharmacy copays are $9 (Tier 1), $30 (Tier 2), $135 (Tier 3), $285 (Tier 4), and n/a (Tier 5).

 

AARP Medicare Advantage Choice Premier – PPO with $29.60 monthly premium, $445 deductible, and $7,550 maximum out-of-pocket expenses. 4.0 summary Star Rating with $0 and $25 office visit copays and $30-$40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $30, $0, and $30 copays respectively. Inpatient hospital visits are subject to a $390 copay for days 1-5, and the outpatient hospital copay is $0-$370. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $15 and $30.

30-day preferred pharmacy copays are 25% (Tier 1), 25% (Tier 2), 25% (Tier 3), 25% (Tier 4), and 25% (Tier 5). 90-day preferred pharmacy copays are $25% (Tier 1), 25% (Tier 2), 25% (Tier 3), 25% (Tier 4), and 25% (Tier 5).

 

AARP Medicare Advantage Plan 1 – HMO-POS with $0 monthly premium, $0 deductible, and $3,900 maximum out-of-pocket expenses.  4.5 summary Star Rating with $0 and $40 office visit copays and $30-$40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $30, $0, and $25 copays respectively. Inpatient hospital visits are subject to a $360 copay for days 1-5, and the outpatient hospital copay is $0-$360. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $15 and $25.

30-day preferred pharmacy copays are $3 (Tier 1), $12 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $9 (Tier 1), $36 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

Aetna Medicare Prime – HMO with $0 monthly premium, $0 deductible, and $4,300 maximum out-of-pocket expenses. $0 and $35 office visit copays and $40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$50, $0, and $5 copays respectively. Inpatient hospital visits are subject to a $265 copay for days 1-7, and the outpatient hospital copay is $0-$250. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $0 (Tier 1), $0 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $0 (Tier 1), $0 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

Aetna Medicare Value– HMO with $0 monthly premium, $0 deductible, and $5,950 maximum out-of-pocket expenses. 4.0 summary Star Rating with $0 and $45 office visit copays and $65 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$75, $0-$15, and $20 copays respectively. Inpatient hospital visits are subject to a $290 copay for days 1-7, and the outpatient hospital copay is $0-$325. The ground ambulance copay is $295, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $0 (Tier 1), $5 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $0 (Tier 1), $10 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

Aetna Medicare Premier– PPO with $29 monthly premium, $0 deductible, and $5,700 maximum out-of-pocket expenses. 4.0 summary Star Rating with $0 and $35 office visit copays and $50 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$75, $0-$5, and $20 copays respectively. Inpatient hospital visits are subject to a $240 copay for days 1-7, and the outpatient hospital copay is $0-$325. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $0 (Tier 1), $0 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $0 (Tier 1), $0 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

Allwell Medicare– HMO with $0 monthly premium, $0 deductible, and $4,100 maximum out-of-pocket expenses. $0 and $40 office visit copays and $40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-10%, $0, and $0-$25 copays respectively. Inpatient hospital visits are subject to a $295 copay for days 1-6, and the outpatient hospital copay is $265. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $25. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $0 (Tier 1), $5 (Tier 2), $37 (Tier 3), $90 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $0 (Tier 1), $15 (Tier 2), $111 (Tier 3), $270 (Tier 4), and n/a (Tier 5).

 

Allwell Medicare– PPO with $0 monthly premium, $0 deductible, and $5,500 maximum out-of-pocket expenses. $5 and $25 office visit copays and $40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$5, $0-$5, and $0-$35 copays respectively. Inpatient hospital visits are subject to a $300 copay for days 1-6, and the outpatient hospital copay is $325. The ground ambulance copay is $295, and rehabilitation therapy visit copays are $35. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $0 (Tier 1), $5 (Tier 2), $37 (Tier 3), $90 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $0 (Tier 1), $15 (Tier 2), $111 (Tier 3), $270 (Tier 4), and n/a (Tier 5).

 

Allwell Medicare Boost– HMO with $0 monthly premium, $200 deductible, and $7,550 maximum out-of-pocket expenses. 4.0 summary Star Rating with $10 and $40 office visit copays and $65 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$40, $0-$10, and $40 copays respectively. Inpatient hospital visits are subject to a $350 copay for days 1-5, and the outpatient hospital copay is $350. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $0 (Tier 1), $5 (Tier 2), $37 (Tier 3), $90 (Tier 4), and 29% (Tier 5). 90-day preferred pharmacy copays are $0 (Tier 1), $15 (Tier 2), $111 (Tier 3), $270 (Tier 4), and n/a (Tier 5).

 

Allwell Medicare Complement– HMO with $29.60 monthly premium, $445 deductible, and $5,500 maximum out-of-pocket expenses. $0 and $40 office visit copays and $40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0 copays respectively. Inpatient hospital visits are subject to a $325 copay for days 1-6, and the outpatient hospital copay is $325. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $30.

30-day preferred pharmacy copays are $2 (Tier 1), $8 (Tier 2), $47 (Tier 3), 45% (Tier 4), and 25% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $24 (Tier 2), $141 (Tier 3), 45% (Tier 4), and n/a (Tier 5).

Anthem MediBlue Plus– HMO with $0 monthly premium, $75 deductible, and $4,900 maximum out-of-pocket expenses. $5 and $40 office visit copays and $35 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$160, $0-$10, and $50-$120 copays respectively. Inpatient hospital visits are subject to a $295 copay for days 1-7, and the outpatient hospital copay is $0-$275. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $35. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $9 (Tier 2), $42 (Tier 3), $95 (Tier 4), and 31% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $27 (Tier 2), $126 (Tier 3), $285 (Tier 4), and n/a (Tier 5).

 

Anthem MediBlue Access Preferred– PPO with $16 monthly premium, $125 deductible, and $4,900 maximum out-of-pocket expenses. $5 and $45 office visit copays and $35 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$160, $0-$20, and $50-$110 copays respectively. Inpatient hospital visits are subject to a $370 copay for days 1-5, and the outpatient hospital copay is $0-$350. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $4 (Tier 1), $13 (Tier 2), $42 (Tier 3), $95 (Tier 4), and 30% (Tier 5). 90-day preferred pharmacy copays are $12 (Tier 1), $39 (Tier 2), $126 (Tier 3), $285 (Tier 4), and n/a (Tier 5).

 

Anthem MediBlue Access Plus– PPO with $54 monthly premium, $60 deductible, and $6,400 maximum out-of-pocket expenses. $10 and $40 office visit copays and $35 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$215, $0-$20, and $50-$110 copays respectively. Inpatient hospital visits are subject to a $310 copay for days 1-7, and the outpatient hospital copay is $0 or 20%. The ground ambulance copay is $265, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $4 (Tier 1), $12 (Tier 2), $42 (Tier 3), $95 (Tier 4), and 32% (Tier 5). 90-day preferred pharmacy copays are $12 (Tier 1), $36 (Tier 2), $126 (Tier 3), $285 (Tier 4), and n/a (Tier 5).

 

Anthem MediBlue Access  – HMO with $29 monthly premium, $150 deductible, and $6,700 maximum out-of-pocket expenses. $10 and $50 office visit copays and $35 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$160, $0-$20, and $50-$110 copays respectively. Inpatient hospital visits are subject to a $310 copay for days 1-7, and the outpatient hospital copay is $0 or 20%. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $4 (Tier 1), $13 (Tier 2), $42 (Tier 3), $95 (Tier 4), and 30% (Tier 5). 90-day preferred pharmacy copays are $12 (Tier 1), $39 (Tier 2), $126 (Tier 3), $285 (Tier 4), and n/a (Tier 5).

 

Anthem MediBlue Access Basic  – Regional PPO with $84 monthly premium, $100 deductible, and $6,400 maximum out-of-pocket expenses. $10 and $40 office visit copays and $35 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$145, $0-$10, and $50-$110 copays respectively. Inpatient hospital visits are subject to a $290 copay for days 1-7, and the outpatient hospital copay is $0 or 20%. The ground ambulance copay is $295, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $20 (Tier 2), $47 (Tier 3), 46% (Tier 4), and 31% (Tier 5). 90-day preferred pharmacy copays are $18 (Tier 1), $45 (Tier 2), $111 (Tier 3), 46% (Tier 4), and n/a (Tier 5).

 

Ascension Complete St. Vincent Reward  – HMO with $0 monthly premium, $390 deductible, and $7,550 maximum out-of-pocket expenses. $0 and $50 office visit copays and $50 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to a $0 copay. Inpatient hospital visits are subject to a $375 copay for days 1-5, and the outpatient hospital copay is $325. The ground ambulance copay is $325, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $6 (Tier 1), $15 (Tier 2), $37 (Tier 3), 46% (Tier 4), and 31% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $60 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

Ascension Complete St. Vincent Secure– HMO with $0 monthly premium, $0 deductible, and $4,500 maximum out-of-pocket expenses. $0 and $30 office visit copays and $30 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to a $0 copay. Inpatient hospital visits are subject to a $395 copay for days 1-6, and the outpatient hospital copay is $270. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $30. Mental health outpatient group and individual therapy visit copays are $30.

30-day preferred pharmacy copays are $0 (Tier 1), $10 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $0 (Tier 1), $10 (Tier 2), $131 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

Ascension Complete St. Vincent Access– HMO with $19 monthly premium, $100 deductible, and $5,200 maximum out-of-pocket expenses. $0 and $35 office visit copays and $35 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to a $0 copay. Inpatient hospital visits are subject to a $335 copay for days 1-5, and the outpatient hospital copay is $325. The ground ambulance copay is $270, and rehabilitation therapy visit copays are $35. Mental health outpatient group and individual therapy visit copays are $35.

30-day preferred pharmacy copays are $0 (Tier 1), $10 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 31% (Tier 5). 90-day preferred pharmacy copays are $0 (Tier 1), $30 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

CareSource Advantage Zero Premium – HMO with $0 monthly premium, $100 deductible, and $6,700 maximum out-of-pocket expenses. $10 and $50 office visit copays and $45 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $35, $35, and $50 copays respectively. Inpatient hospital visits are subject to a $365 copay for days 1-5, and the outpatient hospital copay is $295. The ground ambulance copay is $225, and rehabilitation therapy visit copays are 20%. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $5 (Tier 1), $15 (Tier 2), $45 (Tier 3), $100 (Tier 4), and 31% (Tier 5). 90-day preferred pharmacy copays are $15 (Tier 1), $45 (Tier 2), $135 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

CareSource Advantage – HMO with $24.50 monthly premium, $30 deductible, and $4,600 maximum out-of-pocket expenses. $0 and $35 office visit copays and $35 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0, $0, and $25 copays respectively. Inpatient hospital visits are subject to a $285 copay for days 1-7, and the outpatient hospital copay is $295. The ground ambulance copay is $225, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $35.

30-day preferred pharmacy copays are $4 (Tier 1), $10 (Tier 2), $45 (Tier 3), $100 (Tier 4), and 32% (Tier 5). 90-day preferred pharmacy copays are $12 (Tier 1), $30 (Tier 2), $135 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

Health Alliance Medicare POS Basic Rx – HMO-POS with $51.00 monthly premium, $30 deductible, and $4,600 maximum out-of-pocket expenses. $15 and $50 office visit copays and $65 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $40, $0-$40, and $40 copays respectively. Inpatient hospital visits are subject to a $450 copay for days 1-4, and the outpatient hospital copay is 25%. The ground ambulance copay is $350, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Health Alliance Medicare HMO Basic Rx – HMO with $32.00 monthly premium, $0 deductible, and $6,700 maximum out-of-pocket expenses. $15 and $50 office visit copays and $65 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to 20%, $0-20%, and 20% copays respectively. Inpatient hospital visits are subject to a $300 copay for days 1-6, and the outpatient hospital copay is 20%. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Health Alliance Medicare HMO 40 Rx – HMO with $73.00 monthly premium, $0 deductible, and $4,700 maximum out-of-pocket expenses. $10 and $45 office visit copays and $40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $10, $0-$10, and $10 copays respectively. Inpatient hospital visits are subject to a $275 copay for days 1-7, and the outpatient hospital copay is $275. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Health Alliance Medicare POS 30 Rx – HMO-POS with $105.00 monthly premium, $0 deductible, and $5,500 maximum out-of-pocket expenses. $15 and $45 office visit copays and $40 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $40, $0-$40, and $40 copays respectively. Inpatient hospital visits are subject to a $350 copay for days 1-5, and the outpatient hospital copay is $325. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Health Alliance Medicare HMO 20 Rx – HMO with $125.00 monthly premium, $0 deductible, and $4,000 maximum out-of-pocket expenses. $20 and $40 office visit copays and $25 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $10, $0-$10, and $0 copays respectively. Inpatient hospital visits are subject to a $250 copay for days 1-7, and the outpatient hospital copay is $275. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $20.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Health Alliance Medicare POS 10 Rx – HMO-POS with $165.00 monthly premium, $0 deductible, and $4,500 maximum out-of-pocket expenses. $20 and $40 office visit copays and $30 Urgent Care copay. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0 copays respectively. Inpatient hospital visits are subject to a $250 copay for days 1-8, and the outpatient hospital copay is $275. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $20. Mental health outpatient group and individual therapy visit copays are $30.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Humana Medicare Advantage Plans In Ohio

 

Humana Gold Plus – HMO with $0 monthly premium, $0 deductible, and $3,900 maximum out-of-pocket expenses. $0 and $35 office visit copays and $0-$35 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$105, $0-$35, and $0-$110 copays respectively. Inpatient hospital visits are subject to a $350 copay for days 1-5, and the outpatient hospital copay is $40-$325. The ground ambulance copay is $290, and rehabilitation therapy visit copays are $15-$40. Mental health outpatient group and individual therapy visit copays are $35.

30-day preferred pharmacy copays are $2 (Tier 1), $8 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $24 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

Humana Gold Choice – PFFS with $82 monthly premium, $225 deductible, and $0 maximum out-of-pocket expenses. $20 and $50 office visit copays and $20-$50 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$110, $0-$35, and $20-$110 copays respectively. Inpatient hospital visits are subject to a $390 copay for days 1-5, and the outpatient hospital copay is $50-$365. The ground ambulance copay is $270, and rehabilitation therapy visit copays are $20-$40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $7 (Tier 1), $17 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 29% (Tier 5). 90-day preferred pharmacy copays are $21 (Tier 1), $51 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

HumanaChoice – PPO with $0 monthly premium, $250 deductible, and $7,550 maximum out-of-pocket expenses. $30 and $50 office visit copays and $30-$50 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0-$50, $0-$35, and $30-$110 copays respectively. Inpatient hospital visits are subject to a $490 copay for days 1-4, and the outpatient hospital copay is $50-$465. The ground ambulance copay is $290, and rehabilitation therapy visit copays are $10-$40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $7 (Tier 1), $17 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 28% (Tier 5). 90-day preferred pharmacy copays are $21 (Tier 1), $51 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

Humana Value Plus – PPO with $29.60 monthly premium, $260 deductible, and $7,550 maximum out-of-pocket expenses. 20% office visit copays and 20% Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $0, $0, and 20% copays respectively. Inpatient hospital visits are subject to a $1,700 copay, and the outpatient hospital copay is $65. The ground ambulance copay is $290, and rehabilitation therapy visit copays are 20%. Mental health outpatient group and individual therapy visit copays are 20%.

30-day preferred pharmacy copays are $0 (Tier 1), $15 (Tier 2), $47 (Tier 3), $97 (Tier 4), and 28% (Tier 5). 90-day preferred pharmacy copays are $21 (Tier 1), $51 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

IU Health Plans Medicare Select Plus – HMO with $0 monthly premium, $200 deductible, and $3,250 maximum out-of-pocket expenses. $0-$10 and $40 office visit copays and $45 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to 20%, $10, and $25 copays respectively. Inpatient hospital visits are subject to a $335 copay for days 1-6, and the outpatient hospital copay is $310. The ground ambulance copay is $275, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $3 (Tier 1), $12 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 29% (Tier 5). 90-day preferred pharmacy copays are $9 (Tier 1), $36 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

IU Health Plans Medicare Choice – HMO-POS with $98 monthly premium, $200 deductible, and $6,700 maximum out-of-pocket expenses. $5 and $40 office visit copays and $65 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to 20%, $10, and $25 copays respectively. Inpatient hospital visits are subject to a $335 copay for days 1-6, and the outpatient hospital copay is $325. The ground ambulance copay is $220, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $6 (Tier 1), $15 (Tier 2), $47 (Tier 3), $100 (Tier 4), and 29% (Tier 5). 90-day preferred pharmacy copays are $18 (Tier 1), $45 (Tier 2), $141 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

My TrueAdvantage Select – HMO with $0 monthly premium, $0 deductible, and $4,500 maximum out-of-pocket expenses. $0 and $35 office visit copays and $50 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $10, $10, and $30 copays respectively. Inpatient hospital visits are subject to a $325 copay for days 1-6, and the outpatient hospital copay is $40-$175. The ground ambulance copay is $270, and rehabilitation therapy visit copays are $30 and $35. Mental health outpatient group and individual therapy visit copays are $35.

30-day preferred pharmacy copays are $0 (Tier 1), $7 (Tier 2), $42 (Tier 3), $95 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $0 (Tier 1), $21 (Tier 2), $126 (Tier 3), $285 (Tier 4), and n/a (Tier 5).

 

My TrueAdvantage Choice – PPO with $12 monthly premium, $100 deductible, and $5,000 maximum out-of-pocket expenses. $5 and $40 office visit copays and $50 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $15, $15, and $25 copays respectively. Inpatient hospital visits are subject to a $350 copay for days 1-5, and the outpatient hospital copay is $35-$225. The ground ambulance copay is $260, and rehabilitation therapy visit copays are $35. Mental health outpatient group and individual therapy visit copays are $30 and $35.

30-day preferred pharmacy copays are $2 (Tier 1), $8 (Tier 2), $42 (Tier 3), $95 (Tier 4), and 31% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $24 (Tier 2), $126 (Tier 3), $285 (Tier 4), and n/a (Tier 5).

 

ProMedica Medicare Plan Essential Medical And Drug – HMO with $0 monthly premium, $0 deductible, and $3,400 maximum out-of-pocket expenses. $0 and $35 office visit copays and $35 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $15, $0-15, and $15 copays respectively. Inpatient hospital visits are subject to a $225 copay for days 1-5, and the outpatient hospital copay is $200. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $30. Mental health outpatient group and individual therapy visit copays are $35.

30-day preferred pharmacy copays are $0 (Tier 1), $10 (Tier 2), $45 (Tier 3), $100 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $0 (Tier 1), $30 (Tier 2), $135 (Tier 3), $300 (Tier 4), and n/a (Tier 5).

 

Reid Health Alliance Medicare POS Rx Basic – HMO-POS with $0 monthly premium, $100 deductible, and $6,800 maximum out-of-pocket expenses. $10 and $45 office visit copays and $50 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $15, $0-$10, and $0 copays respectively. Inpatient hospital visits are subject to a $400 copay for days 1-5, and the outpatient hospital copay is 20%. The ground ambulance copay is $300, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 31% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 31% (Tier 5).

 

Reid Health Alliance Medicare POS Rx  – HMO-POS with $35 monthly premium, $0 deductible, and $6,700 maximum out-of-pocket expenses. $10 and $50 office visit copays and $40 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $20, $0-$20, and $30 copays respectively. Inpatient hospital visits are subject to a $325 copay for days 1-6, and the outpatient hospital copay is $425. The ground ambulance copay is $300, and rehabilitation therapy visit copays are $35. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Reid Health Alliance Medicare HMO Rx  – HMO with $51 monthly premium, $0 deductible, and $6,700 maximum out-of-pocket expenses. $20 and $50 office visit copays and $45 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $10, $0-$10, and 20% copays respectively. Inpatient hospital visits are subject to a $300 copay for days 1-6, and the outpatient hospital copay is $345. The ground ambulance copay is $300, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Simplete Richland 1 – HMO with $0 monthly premium, $0 deductible, and $4,000 maximum out-of-pocket expenses. $0 and $25 office visit copays and $40 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $10, $0-$10, and $10 copays respectively. Inpatient hospital visits are subject to a $200 copay for days 1-8, and the outpatient hospital copay is $100 per visit. The ground ambulance copay is $220, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Simplete 1 – HMO with $0 monthly premium, $0 deductible, and $4,000 maximum out-of-pocket expenses. $0 and $25 office visit copays and $40 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $10, $0-$10, and $10 copays respectively. Inpatient hospital visits are subject to a $200 copay for days 1-8, and the outpatient hospital copay is $100 per visit. The ground ambulance copay is $220, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Simplete 2 – HMO with $28 monthly premium, $0 deductible, and $4,500 maximum out-of-pocket expenses. $5-$20 and $25-$40 office visit copays and $40 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $10 copays. Inpatient hospital visits are subject to a $200 copay for days 1-8, and the outpatient hospital copay is $100 per visit. The ground ambulance copay is $220, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Simplete 3 – HMO-POS with $48 monthly premium, $0 deductible, and $4,500 maximum out-of-pocket expenses. $5-$25 and $25-$40 office visit copays and $40 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $10-$25, $0-$25, and $10 copays. Inpatient hospital visits are subject to a $200 copay for days 1-8, and the outpatient hospital copay is $100 per visit. The ground ambulance copay is $220, and rehabilitation therapy visit copays are $40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Simplete Riverside 2 – HMO with $50 monthly premium, $0 deductible, and $4,950 maximum out-of-pocket expenses. $5-$25 and $10-$40 office visit copays and $40 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $10 copays. Inpatient hospital visits are subject to a $225 copay for days 1-8, and the outpatient hospital copay is $100 per visit. The ground ambulance copay is $220, and rehabilitation therapy visit copays are $10-$40. Mental health outpatient group and individual therapy visit copays are $40.

30-day preferred pharmacy copays are $2 (Tier 1), $15 (Tier 2), $47 (Tier 3), 50% (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $45 (Tier 2), $141 (Tier 3), 50% (Tier 4), and 33% (Tier 5).

 

Zing Choice IN – HMO with $0 monthly premium, $0 deductible, and $3,500 maximum out-of-pocket expenses. $0 and $35 office visit copays and $10 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $25, $0, and $5 copays respectively. Inpatient hospital visits are subject to a $300 copay for days 1-5, and the outpatient hospital copay is $40-$250. The ground ambulance copay is $250, and rehabilitation therapy visit copays are $20. Mental health outpatient group and individual therapy visit copays are $35.

30-day preferred pharmacy copays are $2 (Tier 1), $10 (Tier 2), $35 (Tier 3), $95 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $30 (Tier 2), $105 (Tier 3), $285 (Tier 4), and n/a (Tier 5).

 

Zing Essential Wellness IN – HMO C-SNP with $0 monthly premium, and $0 deductible. $0 and $20 office visit copays and $10 Urgent Care copays. In-network diagnostic tests, lab services, and outpatient x-rays are subject to $25, $0, and $0 copays respectively. Inpatient hospital visits are subject to a $200 copay for days 1-5, and the outpatient hospital copay is $25-$250. The ground ambulance copay is $175, and rehabilitation therapy visit copays are $20. Mental health outpatient group and individual therapy visit copays are $20.

30-day preferred pharmacy copays are $2 (Tier 1), $10 (Tier 2), $35 (Tier 3), $95 (Tier 4), and 33% (Tier 5). 90-day preferred pharmacy copays are $6 (Tier 1), $30 (Tier 2), $105 (Tier 3), $285 (Tier 4), and n/a (Tier 5).