2015 IU Health Plans Select Plus Plan

Below, you will find a snapshot of the IU Health Plans 2015 Select Plan Plus HMO plan as well as links to its Summary of Benefits.

The IU Health Plans Select Plan Plus HMO plan offers the Select Plan Medical benefits plus Part D prescription drug coverage for one premium.

IU Health Medicare Select Plus Plan HMO Details

COST: $42

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Annual Deductible

$0

Inpatient Hospital/Mental Health

$235 1-7 Days Inpatient
$235  1-6 Days Mental Health
$0 Days 7 or 8 - 90

Skilled Nursing (No hospital stay required)

$0 1-20 days

$150 21-100 days

Home Health $0
Primary Care Physician $15
Specialist $45
Chiropractor $20
Podiatry

$15

Outpatient Surgery $265
Ambulance $225
Emergency

$65

Urgent Care $50
Durable Medical Equipment 20%
Diabetic Supplies $0
Diagnostic Tests/Lab $10
X-rays/Therapeutic Radiology $25
Diagnostic Radiology $125
Part B Covered Drugs 20%
Preventive Screenings $0
Annual Physical Exam $0
Fitness Center Membership

up to $200 reimbursement/yr.

Preventive Dental $10
Routine Vision Exam $0
Eyeglasses (lenses/frames) $40
Out-of-pocket Cost Protection $4,750
Plan Limit No limit
Annual Deductible $0
Tier 1 (Preferred Generic)

$6 30 day

$18 90 day

Tier 2 (Non-Preferred Generic)

$15 30 day

$44 90 day

Tier 3 (Preferred Brand)

$45 30 day

$126 90 day

Tier 4 (Non- Preferred Brand)

$95 30 day

$266 90 day

Tier 5 (Specialty) 33% 30 day
Coverage Gap after $2,960 until out-of-pocket is reached ($4,700)

Tier 1 & 2 Gen. 65%

Tier 3,4 & 5 Brand 45%

Summary of Benefits Detailed Benefits Comparison

 

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact us about the plan. Limitations, copayments, and restrictions may apply. Benefits may change on January 1st of each year.

MODIFY DATE: 09/26/2014 9:54:45 AM PMMODIFIED BY: jnaffzig@iuhealth.org