2018 summary of benefits - memorial hermann health...

2018 Summary of BenefitsMEMORIAL HERMANN ADVANTAGE HMO AND PPO.

This Summary of Benefits document provides an outline of health and drug services covered by Memorial Hermann Advantage HMO plan January 1, 2018 – December 31, 2018.

Memorial Hermann Advantage HMO is provided by Memorial Hermann Health Plan, Inc., a Medicare Advantage organization with a Medicare contract. Enrollment in this plan depends on contract renewal.

This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage."

To join Memorial Hermann Advantage HMO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

You must continue to pay your Medicare Part B premium.

Our service area includes the following counties in Texas: Fort Bend, Harris, and Montgomery.

Y0110_FL_SBCAHMO18_CMS Accepted 09/19/2017 17E1-AHMO-SBC

2018

Summary of Benefits Memorial Hermann Advantage HMO H7115-001

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Who can join?

To join Memorial Hermann Advantage HMO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

• Our services areas are listed on the front cover of this Summary of Benefits.

What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more.

• Our plan members get all of the benefits covered by Original Medicare. For some ofthese benefits, you may pay more in our plan than you would in Original Medicare. Forothers, you may pay less.

• Our plan members also get more than what is covered by Original Medicare. Some of theextra benefits are outlined in this booklet.

We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider.

• You can see the complete plan formulary (list of Part D prescription drugs) and anyrestrictions on our website, healthplan.memorialhermann.org/medicare.

• Or, call us and we will send you a copy of the formulary.

Which doctors, hospitals, and pharmacies can I use? Memorial Hermann Advantage HMO has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

• You must generally use network pharmacies to fill your prescriptions for covered Part Ddrugs.

• You can see our plan's provider directory at our website(healthplan.memorialhermann.org/medicare).

• You can see our plan's pharmacy directory at our website (healthplan.memorialhermann.org).Or, call us and we will send you a copy of the provider and pharmacy directories.

How will I determine my drug costs?

Our plan groups each medication into one of five "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage.

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Things to Know About Memorial Hermann Advantage HMO

Memorial Hermann Advantage HMO Phone Numbers, Days and Hours of Operations and Website information

• If you have question regarding becoming a member of Memorial Hermann Advantage HMO call us toll-free at 866.344.8240, TTY/TDD 711. We are open from October 1 to February 14, 7 days a week from 8:00 a.m. to 8:00 p.m. Central time. During February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Central time. A licensed agent may answer your call.

• If you are a member of this plan, and would like an explanation of your requested Summary of Benefits call Customer Service toll-free at 855.645.8448 (TTY: 711). We are open from October 1 to February 14, 7 days a week from 8:00 a.m. to 8:00 p.m. Central time. During February 15 to September 30, you can call us Monday through Friday from8:00 a.m. to 8:00 p.m. Central time.

• Or, you may visit our website at healthplan.memorialhermann.org/medicare

This document is available in other formats such as Braille and large print. This document may be available in a non-English language. For additional information, call us at 855.645.8448 (TTY: 711).

If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at www.medicare.gov or get a copy by calling 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users should call 1.877.486.2048.

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Sections in this booklet

Monthly Premium and Max Out of Pocket

Preventative Care

Hearing, Dental and Vision Benefits

Medical and Hospital Benefits

Prescription Drug Benefits

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Premiums and Benefits Memorial Hermann Advantage HMO

What you should know

Monthly Plan Premium You pay nothing You must continue to pay your Medicare Part B premium.

Deductible No deductible This plan does not have a medical deductible.

Maximum Out-of-Pocket Responsibility (does not include Part D prescription drugs)

You pay no more than $6,700 annually.

The most you pay for copays, coinsurance, and other costs for medical services for the year.

Inpatient Hospital Coverage

You pay $250 per day for days 1 through 5

You pay nothing for days 6 through 90

Our plan covers an unlimited number of days for an inpatient hospital stay.

Requires prior authorization.

Doctors Visits Primary Care Physician Visit: You pay $5 per visit

Specialist Visit: You pay $50 per visit

Cost share may apply for Part B injectables.

For detailed information regarding additional cost shares for the other covered in office procedures/services provided by the Physician/Specialist, see the Medical Benefits Chart in Chapter 4 of the Evidence of Coverage.

Preventive Care You pay nothing Preventive services include, but are not limited to: yearly wellness visit, colorectal screenings, flu vaccines, and many more.

Any additional preventive services approved by Medicare during the contract year will be covered.

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Outpatient Hospital Coverage

You pay $300 for each Medicare-covered outpatient hospital facility visit.

You pay $80 per visit If you are admitted to the hospital within 48 hours, you do not have to pay your share of the cost for emergency care.

Hearing Services Basic hearing and balance exam performed by a primary care doctor: You pay $5

Hearing to diagnose and treat hearing and balance issues: You pay $50

Annual Hearing Exam: You pay $50

Hearing Aid(s) per year: $400 annual benefit

$400 annual benefit to go towards the purchase of hearing aids.

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Diagnostic Services/Labs/Imaging

Blood services (transfusions)

Non-radiologic diagnostic

procedures/tests

Diagnostic radiology services (MRI, CT, PET)

Lab services

Therapeutic radiology services (radiation)

Outpatient X-rays

You pay nothing

You pay $75*

You pay $200*

You pay $5*

You pay $25*

You pay $10*

Costs for these services may be different if received in an outpatient surgery setting.

*per test

*per test/procedureprior authorization required

*per lab service

*per session

*per x-ray

Urgently Needed Services

You pay $35 per visit

Emergency Care

For Colorectal Screenings, please note that a colonoscopy conducted for polyp removal or biopsy is a surgical procedure subject to the outpatient surgery cost sharing described later in this benefit grid.

Preventive Care (cont.)

Dental Services

Comprehensive Services: You pay $75

In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare.

We cover: Medicare-covered dental services limited to surgery of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician.

Prior Authorization required.

Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing

Eye Exam Performed by Optician/Optometrist/ Ophthalmologist: You pay $50

Eyewear per year(Contact Lenses, Eyeglasses (frames and lenses)): $200 annual benefit

$200 annual benefit to go towards the purchase of eye-wear and contacts.

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Limited dental services (does not include services in connection with care, treatment, filling, removal, or replacement of teeth).

Skilled Nursing Facility You pay nothing for days 1 through 20

You pay $100 per day for days 21 through 100

Our plan covers up to 100 days in a skilled nursing facility per 60 day benefit period.


Rehabilitation Services Cardiac (heart) Rehab Services: You pay $25 per visit

Pulmonary Services: You pay $25 per visit

Occupational Therapy Visit: You pay $25 per visit

Physical Therapy and Speech and Language Therapy Visit: You pay $25 per visit

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Mental Health Services (including Inpatient)

Inpatient Services: You pay $250 per day for days 1 through 5 You pay nothing for days 6 through 90

Outpatient Services Outpatient group therapy visit: You pay $40

Outpatient individual therapy visit: You pay $40

Inpatient visit: Our plan covers an unlimited number of days for an inpatient hospital stay. Prior Authorization required.

Outpatient individual therapy visit corresponds to total cost for each Medicare-covered individual therapy visit provided by a non-physician.

Premiums and Benefits Memorial Hermann Advantage HMO


Ambulance You pay $250 per one-way trip

Transportation Memorial Hermann Advantage HMO does not offer transportation services.

You pay $25 Foot exams and treatmentRoutine Foot Care Limitations may apply.

You pay 20% coinsurance

Silver&Fit® Program: You pay nothing

24 Hour Nurse Line: You pay nothing

Memorial Hermann Advantage offers Silver&Fit® club membership, Home Fitness Program, fitness challenges and more.

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Prior Authorization required for items over $1,000.

Medicare Part B Drugs For Part B drugs such as chemotherapy drugs: You pay 20% coinsurance

Other Part B Drugs: You pay 20% coinsurance

Wellness Programs (e.g. fitness)

Durable Medical Equipment/Supplies

Foot Care (podiatry services)

Prescription Drug:

Cost-Sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional pharmacy-specific cost-sharing and the phases of the benefit, please call us at 855.645.8448 (TTY: 711) or access our Evidence of Coverage online.

Initial Coverage: Standard Retail Cost-Sharing After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $3,750. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

Deductible: $300 per year for Tier 4 and Tier 5 Part D prescription drugs.

You may get your drugs at network retail pharmacies and mail order pharmacies.

Initial Coverage – Standard Retail

Cost-Sharing (After you pay your

deductible, if applicable) Tier

One-Month Supply

Two-Month Supply

Three-Month Supply

Tier 1 (Preferred Generic)

$2.00 $4.00 $5.00

Tier 2 (Generic) $15.00 $30.00 $37.50

Tier 3 (Preferred Brand) $45.00 $90.00 $112.50

Tier 4 (Non-Preferred Brand)

$99.00 $198.00 $247.50

Tier 5 (Specialty Tier Drugs)

27% Not Available Not Available

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Initial Coverage: Standard Mail Order



One-Month Supply

Two-Month Supply

Three-Month Supply


$2.00 $4.00 $4.00

Tier 2 (Generic)

$15.00 $30.00 $30.00

Tier 3 (Preferred Brand)

$45.00 $90.00 $90.00


$99.00 $198.00 $198.00



If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

Coverage Gap: Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750.

After you enter the coverage gap, you pay 35% of the price for brand name drugs plus a portion of the dispensing fee and 44% of the price for generic drugs. 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 $5,000, you pay the greater of:

• 5% of the cost, or• $3.35 copay for generic or a preferred multi-source drug (including brand

drugs treated as generic) and a• $8.35 copay for all other drugs.

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This Summary of Benefits document provides an outline of health and drug services covered by Memorial Hermann Advantage PPO plan January 1, 2018– December 31, 2018.

Memorial Hermann Advantage PPO is provided by Memorial Hermann Health Insurance Company, a Medicare Advantage organization with a Medicare contract. Enrollment in this plan depends on contract renewal.

This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage."

To join Memorial Hermann Advantage PPO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

You must continue to pay your Medicare Part B premium.

Our service area includes the following counties in Texas: Fort Bend, Harris, and Montgomery.

Y0110_FL_SBCAPPO18_CMS Accepted_09/19/2017 17E1-APPO-SBC

2018 Summary of Benefits Memorial Hermann Advantage PPO H2968-001

1 │ Page

Who can join? To join Memorial Hermann Advantage PPO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

• Our services areas are listed on the front cover of this Summary of Benefits.

What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more.

• Our plan members get all of the benefits covered by Original Medicare. For some ofthese benefits, you may pay more in our plan than you would in Original Medicare. Forothers, you may pay less.

• Our plan members also get more than what is covered by Original Medicare. Some of theextra benefits are outlined in this booklet.

We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider.

• You can see the complete plan formulary (list of Part D prescription drugs) and anyrestrictions on our website, healthplan.memorialhermann.org/medicare.

• Or, call us and we will send you a copy of the formulary.

Which doctors, hospitals, and pharmacies can I use? Memorial Hermann Advantage PPO has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Out-of-network/non-contracted providers are under no obligation to treat Memorial Hermann Advantage PPO members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. 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.

• You must generally use network pharmacies to fill your prescriptions for covered Part Ddrugs.

• You can see our plan's provider directory at our website(healthplan.memorialhermann.org/medicare/resource-center).

• You can see our plan's pharmacy directory at our website(healthplan.memorialhermann.org/medicare/resource-center).

Or, call us and we will send you a copy of the provider and pharmacy directories.

2 │ Page

How will I determine my drug costs?

Our plan groups each medication into one of five "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage.

Things to Know About Memorial Hermann Advantage PPO

Memorial Hermann Advantage PPO Phone Numbers, Days and Hours of Operations and Website information

• If you have question regarding becoming a member of Memorial Hermann Advantage PPOcall us toll-free at 866.344.8240, TTY/TDD: 711. We are open from October 1 to February14, 7 days a week from 8:00 a.m. to 8:00 p.m. Central time. During February 15 toSeptember 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Centraltime. A licensed agent may answer your call.

• If you are a member of this plan, and would like an explanation of your requested Summaryof Benefits call Customer Service toll-free at 855.645.8448 (TTY: 711). We are open fromOctober 1 to February 14, 7 days a week from 8:00 a.m. to 8:00 p.m. Central time. DuringFebruary 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00p.m. Central time.

• Or, you may visit our website at healthplan.memorialhermann.org/medicare

This document is available in other formats such as Braille and large print. This document may be available in a non-English language. For additional information, call us at 855.645.8448 (TTY: 711).

If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling 1.800.MEDICARE 1.800.633.4227, 24 hours a day, 7 days a week. TTY users should call 1.877.486.2048.

3 │ Page

Sections in this booklet

Monthly Premium and Max Out of Pocket

Preventative Care

Hearing, Dental and Vision Benefits

Medical and Hospital Benefits

Prescription Drug Benefits

4 │ Page

Premiums and Benefits Memorial Hermann

Advantage PPO What you should know

Monthly Plan Premium You pay $25 per month In addition, you must keep paying your Medicare B premium.

Deductible No deductible This plan does not have a medical deductible.

Maximum Out-of-Pocket Responsibility (does not include prescription drugs)

You pay no more than $6,700 annually for services you receive from In-Network providers.

You pay no more than $9,500 annually for services you receive from any provider. Your limit for services received from In-Network providers will count toward this limit.

The most you pay for copays, coinsurance, and other costs for medical services for the year.

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Doctors Visits

Primary Care

Specialists

Primary Care Physician Visit: In-Network: You pay $5 per visit Out-of-Network: You pay 40% coinsurance

Specialist Visit: In-Network: You pay $50 per visit Out-of-Network: You pay 40% coinsurance

Cost share may apply for Part B injectables.

For detailed information regarding additional cost shares for the other covered in office procedures/services provided by the Physician/Specialist, see the Medical Benefits Chart in Chapter 4 of the Evidence of Coverage. Please note: Cost to visit non-participating providers is based on the Medicare allowable.

Inpatient Hospital Coverage

In-Network: You pay $300 per day for days 1 through 5. You pay nothing for days 6 through 90. Out-of-Network: You pay 40% coinsurance for days 1 through 90

Our plan covers an unlimited number of days for an inpatient hospital stay.


Outpatient Hospital Coverage

You pay $450 for each Medicare-covered outpatient hospital facility visit.

Preventive Care In-Network: You pay nothing

Out-of-Network: You pay 40% coinsurance

Any additional preventive services approved by Medicare during the contract year will be covered. For Colorectal Cancer Screenings, please note that a colonoscopy or sigmoidoscopy conducted for polyp removal or biopsy is a surgical procedure subject to the outpatient surgery cost sharing described later in this benefit grid.

Emergency Care In-Network or Out-of-Network: You pay $80 per visit

If you are admitted to the hospital within 48 hours, you do not have to pay your share of the cost for emergency care.

Urgently Needed Services In-Network or Out-of-Network: You pay $35 per visit

Diagnostic Services/Labs/Imaging

Blood services (transfusions)

Non-radiologic diagnostic procedures/tests

Diagnostic radiology services (MRI, CT, PET)

Lab services

Therapeutic radiology services (radiation)

Outpatient X-rays

In-Network: You pay nothing Out-of-Network: You pay 40% coinsurance

In-Network: You pay $75* Out-of-Network: You pay 40% coinsurance





Costs for these services may be different if received in an outpatient surgery setting.

*per test

*per test/procedurePrior Authorization required.

*per lab service

*per session

*per x-ray

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Hearing Services Basic hearing and balance exam performed by a primary care doctor: In-Network: You pay $5 Out-of-Network: You pay 40% coinsurance

Hearing exam to diagnose and treat hearing and balance issues: In-Network: You pay $50 Out-of-Network: You pay 40% coinsurance

Annual Hearing Exam: In-Network: You pay $10 Out-of-Network: You pay 40% coinsurance

Hearing Aid(s) per year: $250 annual benefit

$250 annual benefit towards the purchase of hearing aids for In-Network or Out-of-Network.

Dental Services Limited dental services (this does not include services in connection with care,treatment, filling, removal, or replacement of teeth):

Comprehensive Services: You pay $150

In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare.

We cover: Medicare-covered dental services limited to surgery of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician.


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Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-Network: You pay nothing Out-of-Network: You pay 40% coinsurance

Eye Exam Performed by Optician/Optometrist/ Ophthalmologist: In-Network: You pay $50 Out-of-Network: You pay 40% coinsurance

Eyewear per year (Contact Lenses, Eyeglasses (frames and lenses)): $150 annual benefit

$150 annual benefit towards the purchase of eye-wear and contacts In-Network or Out-of-Network.

Mental Health Services (including inpatient)

Inpatient Services In-Network: You pay $300 per day for days 1 through 5. You pay nothing for days 6 through 90. Out-of-Network: You pay 40% coinsurance for days 1 through 90

Outpatient Services: Outpatient group therapy visit: In-Network: You pay $40 Out-of-Network: You pay 40% coinsurance

Outpatient individual therapy visit: In-Network: You pay $40 Out-of-Network: You pay 40% coinsurance

Inpatient visit: Our plan covers an unlimited number of days for an inpatient hospital stay. Prior Authorization required.

Outpatient individual therapy visit corresponds to total cost for each Medicare-covered individual therapy visit provided by a non-physician.

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Skilled Nursing Facility In-Network: You pay nothing for days 1 through 20 You pay $150 per day for days 21 through 100

Out-of-Network: You pay 40% coinsurance for days 1-100

Our plan covers up to 100 days in a skilled nursing facility per 60 day benefit period. Prior Authorization required.

Rehabilitation Services Cardiac (heart) Rehab Services: In-Network: You pay $25 per visitOut-of-Network: You pay 40% coinsurance

Pulmonary Services: In-Network: You pay $25 per visitOut-of-Network: You pay 40% coinsurance

Occupational Therapy Visit: In-Network: You pay $25 per visitOut-of-Network: You pay 40% coinsurance

Physical Therapy and Speech and Language Therapy Visit: In-Network: You pay $25 per visitOut-of-Network: You pay 40% coinsurance

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Premiums and Benefits (continued)

Memorial Hermann Advantage PPO


Ambulance In-Network or Out-of-Network: You pay $300 copay per one-way trip

Transportation Memorial Hermann Advantage PPO does not offer transportation services.


Medicare Part B Drugs For Part B drugs such as chemotherapy drugs: In-Network: You pay 20% coinsurance Out-of-Network: You pay 40% coinsurance

Other Part B Drugs: In-Network: You pay 20% coinsurance Out-of-Network: You pay 40% coinsurance

10 │ Page

Wellness Programs Silver& Fit Program: You pay nothing

24 Hour Nurse Line: You pay nothing

Memorial Hermann Advantage offers Silver&Fit® club membership, Home Fitness Program, fitness challenges and more at no cost to you.

Foot Care (podiatry services)

In-Network: You pay $25

Foot exams and treatment Routine Foot Care Limitations may apply.

Durable Medical Equipment/Supplies

In-Network: You pay 20% coinsurance


Prior Authorization required for items over $1,000.

Prescription Drug:

Cost-Sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional pharmacy-specific cost-sharing and the phases of the benefit, please call us at 855.645.8448 (TTY: 711) or access our Evidence of Coverage online.

Initial Coverage: Standard Retail Cost-Sharing After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $3,750. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

Deductible: $300 per year for Tier 4 and Tier 5 Part D prescription drugs.

You may get your drugs at network retail pharmacies and mail order pharmacies.

Initial Coverage – Standard Retail

Cost-Sharing (After you pay

your deductible, if applicable) Tier

One-Month Supply

Two-Month Supply

Three-Month Supply


$5.00 $10.00 $12.50

Tier 2 (Generic) $15.00 $30.00 $37.50

Tier 3 (Preferred Brand) $45.00 $90.00 $112.50


$99.00 $198.00 $247.50



11 │ Page

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

Coverage Gap: Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750.

After you enter the coverage gap, you pay 35% of the price for brand name drugs plus a portion of the dispensing fee and 44% of the price for generic drugs. 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 $5,000, you pay the greater of: • 5% of the cost, or• $3.35 copay for generic or a preferred multi-source drug (including brand

drugs treated as generic) and a• $8.35 copay for all other drugs.

Initial Coverage: Standard Mail Order



One-Month Supply

Two-Month Supply

Three-Month Supply


$5.00 $10.00 $10.00

Tier 2 (Generic)

$15.00 $30.00 $30.00

Tier 3 (Preferred Brand)

$45.00 $90.00 $90.00


$90.00 $198.00 $198.00



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memorialhermannadvantage.org

866.344.8240 (TTY 711) 8 a.m. to 8 p.m., 7 days a week (Oct. 1 – Feb. 14) 8 a.m. to 8 p.m., Monday – Friday (Feb. 15 – Sept. 30)

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2018 summary of benefits - memorial hermann health...

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