2021 MyTruAdvantage Select (HMO)

Highlights of this plan include our $0 per month premiums, $0 medical deductibles and low copays, $0 PCP (Primary Care Provider) visits, and $0 or low copays for generic drugs.
We also have extras like vision, hearing and fitness, as well as rich dental benefits. Finally, with advantages like an out-of-pocket maximum of just $4500, skilled nursing benefit that doesn't require an inpatient hospital stay first, no referrals for in-network specialists, and worldwide coverage for emergency and urgently needed care up to $25000, the advantage is yours with MyTruAdvantage Select (HMO). Please see below for more detail.

  • $0 monthly premium
  • $0 medical deductible
  • $0 prescription deductible
  • $0 PCP copay
  • Enhanced dental benefit
  • Vision with hardware allowance
  • Hearing aid discounted pricing
  • Over-the-counter allowance
  • Preferred pharmacy prescription pricing
  • Gym membership and at-home fitness kits

*Service area includes the following counties: Bartholomew, Brown, Clay, Hamilton, Hancock, Howard, Jackson, Jennings, Johnson, Madison, Marion, Parke, Posey, Sullivan, Vanderburgh, Vermillion, Vigo, and Warrick

In-network Benefits

Annual Deductible

$0
 

The amount you’ll pay for most covered in-network medical services before you start paying only copayments or coinsurance and MyTruAdvantage pays the balance.

Out-of-Pocket Maximum

$4500
 

This is the most you pay during a calendar year for in-network and out-of-network services before MyTruAdvantage begins to pay 100% of the allowed amount. This limit includes copayments and coinsurance payments. It does not include your monthly premium or Part D drug costs.

Inpatient Hospital Care

$325$0

Per day, days 1 - 6Per day, days 7 and beyond

Outpatient Hospital Care

$175

for each visit

Includes Ambulatory Surgical Center, Outpatient hospital and Observation Visits.

Doctor Visits

$0$35

Each primary care physician (PCP) visitEach specialist visit

Preventive Care

$0

Each service

Includes immunizations, physical exams (initial exam and annual wellness visit), colorectal screening, pap smears and pelvic exams screening, prostate cancer screening, bone mass measurement, mammography screening, and outpatient hospital services - preventive

Emergency & Urgent Care

$90$50

Each emergency room visitEach urgent care visit

Lab Services (Outpatient Diagnostic)

$10

Each service

Tests and Procedures (Outpatient Diagnostic)

$10

Each service

Outpatient X-rays

$30

Each service

Diagnostic Radiological Services

$225

Each service

Complex Radiology/imaging (such as MRI and CT scan)

Radiation Therapy

$40

Each service

Routine Hearing Exam

$0

up to one per year

Routine hearing services must be provided by a TruHearing provider.

Hearing Aid

$699, $999

Depending on the type

Preventive (Routine) Dental

$0

Each service

Cleanings & exams (2 per year), and bitewing x-rays (one per year)

$1000 maximum benefit coverage per year

Routine Vision Exam

$0

Each exam

Routine vision services must be provided by an "Eyemed Select" provider.

Glasses/Contacts

$150

Annual benefit amount

Mental Health Care Inpatient Visit

$0/$325

Each day, Days 1-5/days 6-90

Outpatient Group and Individual Therapy

$30

Each visit

Skilled Nursing Facility

$0/$184

Each day, Days 1-5/days 6-100

This plan covers up to 100 days each benefit period

Physical Therapy

$30

Each visit

Ambulance

$270/$325

Each trip, Ground/air

Transportation

Not Covered
 

Over-the-Counter (OTC) Card

$45

Every 3 months

The OTC benefit offers you an easy way to get generic over-the-counter health and wellness products by phone at 1-888-628-2770 (TTY: 711) or online at www.cvs.com/otchs/MyTruAdvantage. You order from a list of approved OTC items, and OTC Health Solutions will mail them directly to your home address.

Fitness Benefit

$0
 

Includes a no-cost gym membership at a participating fitness center or YMCA, one Stay Fit Kit (options include a Fitbit, Garmin, yoga, or strength kit), and 2 home fitness kits, where you can choose from 34 options like Aqua, Tai Chi, Chair-based exercise and more.

Prescription Drug Benefits

Medicare Part B Drugs may require prior authorization. The copay for chemotherapy drugs and other Part B drugs is 20%. The below tables are broken out by preferred pharmacy, standard pharmacy and mail order. Please see the Pharmacy list to see what pharmacies are in which category.

Download the Pharmacy List

Annual Deductible

$0

For all tiers

Tier 1 (Preferred Generic), Tier 2 (Non-Preferred Generic), Tier 3 (Preferred Brand), Tier 4 (Non-Preferred Drug), Tier 5 (Specialty Tier)

Initial Coverage

 

 

After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $4130. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. Once you reach that amount, you will enter the Coverage Gap. You may get your drugs at network retail pharmacies and mail order pharmacies.

Tier 1 (Preferred generic)

$0$0$5

Preferred retail (30-day)Standard retail (30-day)Mail order (90-day)

Tier 2 (Non-preferred Generic)

$7$0$12

Preferred retail (30-day)Standard retail (30-day)Mail order (90-day)

Tier 3 (Preferred Brand)

$42$141$47

Preferred retail (30-day)Standard retail (30-day)Mail order (90-day)

Tier 4 (Non-preferred Drug)

$95$300$100

Preferred retail (30-day)Standard retail (30-day)Mail order (90-day)

Tier 5 (Specialty)

33% of cost

Preferred and standard retail (30-day)

Coverage Gap

 

 

When you reach your total yearly drug cost (which includes what our plan has paid and what you have paid) of $4130, you'll enter what is called a coverage gap. At this time, you wil pay 25% of the plan's cost for covered generic drugs and 25% of the plan's cost for covered brand drugs, plus dispensing fee, until your total costs reach $6550.

Most Medicare plans have this coverage gap (also called the "donut hole"), but not everyone will enter the coverage gap.

Catastrophic Coverage

 

 

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6550, you pay the greater of: 5% of the cost, or $3.70 copay for generic (including brand drugs treated as generic) and a $9.20 copay for all other drugs

 


*Certain procedures, services and drugs may need advance approval from your plan. This is called a "prior authorization" or "preauthorization". Please refer to the plan's Evidence of Coverage for all services that require Prior Authorization.