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Monthly Premium You must continue to pay your Medicare Part B premium. If you have a late enrollment penalty, it will still apply.
$105*
Max out of pocket
$4,550
Deductible
$0
Copays (PCP/Specialist)
$0/$30
Dental
$0 preventive - 2 cleanings, 2 exams, 2 fluoride treatments & a set of bite-wing x-rays per year. Full mouth x-rays are covered once every 5 years. $0 copay, no deductible, maximum benefit of $2000 per calendar year. Comprehensive dental covered 50%. Implants & dentures are not covered. PPO only network.
Over-the-counter (OTC) benefit
Flex card available
Vision
$0 routine exam. $150 yearly allowance for eyeglasses or contact lenses. 20% discount over $150 base allowance for frames, lenses, lens options. 40% discount applies on the purchase of any additional eyeglasses; must use EyeMed provider.
Hearing / Hearing Aids
$0 routine exam. Copays for hearing aids - 1 per ear, per calendar year; must use NationsHearing.
Inpatient Hospital
$300 Days 1-5; $0 Days 6-90; unlimited days
Preventive Care
No copay for services considered preventive.
Outpatient Diagnostic Labs, Procedures, Tests
$0 lab tests. $0 - $150 copay depending on service.
Emergency Room / Urgent Care
$130/$45; worldwide coverage
Physical, Occupational and Speech Therapy
$10
Flex Card
$153 per quarter with rollover to next quarter for OTC & Healthy food/produce***, includes retail over-the-counter
Transportation
12 one-way trips

* You must continue to pay your Medicare Part B premium. If you have a late enrollment penalty, it will still apply.

**Depending on your level of Medicaid eligibility, you may not be responsible for the copayments, coinsurance or deductibles for these listed services.

***This benefit is a special supplemental benefit for the chronically ill (SSBCI) and is made available to members with one or more qualifying chronic conditions.  Not all members will qualify for this benefit. Qualifying chronic conditions include but are not limited to diabetes, cardiovascular disorders, chronic lung disorders, cancer, and dementia.  For a complete list of qualifying chronic conditions please see the plan’s Evidence of Coverage (EOC).

HAP Senior Plus (HMO-POS), HAP Medicare MedicalAccess (HMO), HAP Senior Plus Henry Ford Tiered Access (HMO), HAP Medicare Connect (HMO), HAP Medicare Superior (HMO), Henry Ford Select (HMO), HAP Senior Plus (PPO), HAP Medicare Explore (PPO), HAP Medicare Prime (PPO), HAP Member Assist (PPO), HAP Medicare Diabetes and Heart (HMO C-SNP), and HAP CareSource™ MI Coordinated Health (HMO D-SNP) has a contract with Medicare. Enrollment depends on contract renewal.