Benefits

The benefit information provided is a brief summary, not a complete description of benefits.  For more information contact the plan.  Limitations, copayments, and restrictions may apply.  Benefits, formulary, pharmacy network, provider network, premium, and/or co-payments/co-insurance may change on January 1 of each year.

The chart below shows some of your benefits available when you are a member of Advantage by Superior HealthPlan. For more detailed information on your benefits, please refer to your Summary of Benefits.

Advantage by Superior HealthPlan
CY2014 Brief Overview of Benefits
Service Area Bexar, Collin, Dallas, Nueces, and Rockwall Counties
Benefit Category
Monthly Premium $0
Summary of Benefits View Summary of Benefits
Maximum Out Of Pocket $3,400
Includes Part D Yes – See Below
Part B Deductible $0
Inpatient Hospital Care $0
Inpatient Mental Health Care $0
Skilled Nursing Facility (SNF) $0
Home Health $0 copay for Medicare-covered home health visits
Hospice You must get care from a Medicare-certified hospice
Doctor Visits $0 copay for each Medicare-covered primary care doctor and specialist visit.
Chiropractic Services $0 of the cost for each Medicare-covered chiropractic visit
Podiatry Services $0 of the cost for each Medicare-covered podiatry visit
Outpatient Mental Health Care $0 copay for:
-each Medicare-covered individual therapy visit
-each Medicare-covered group therapy visit
-each Medicare-covered individual therapy visit with a psychiatrist
-each Medicare-covered group therapy visit with a psychiatrist
$0 copay for Medicare-covered partial hospitalization program services
Outpatient Substance Abuse Care $0 copay for:
-each Medicare-covered individual substance abuse outpatient treatment visit
-each Medicare-covered group substance abuse outpatient treatment visit
Outpatient Services $0 copay for each ambulatory surgical center visit
$0 copay for each outpatient facility visit
Ambulance Services $0 copay for Medicare-covered ambulance benefits
Emergency Care $0 copay for Medicare-covered emergency room visits
Urgently Needed Care $0 copay for Medicare-covered urgently needed care visits
Outpatient Rehabilitation Services
Occupational Therapy, Physcial Therapy,
Speech/Language Therapy
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits
Durable Medical Equipment (DME) $0 copay for Medicare-covered durable medical equipment
Prosthetic Devices $0 copay for Medicare-covered:
-prosthetic devices
-medical supplies related to prosthetics, splints, and other devices
Diabetes Program and Supplies $0 copay for Medicare-covered Diabetes self-management training
$0 copay for:
-Medicare-covered Diabetes monitoring supplies
-Medicare-covered Therapeutic shoes or inserts
Diagnostic Tests, X-rays, Lab Services, and Radiology Services $0 copay for lab services
$0 of the cost for Medicare-covered diagnositc procedures & tests
$0 of the cost for Medicare-covered X-rays
$0 of the cost for Medicare-covered diagnostic radiology services (not including x-rays)
$0 of the cost for Medicare-covered therapeutic radiology services
Cardiac & Pulmonary Rehabilitation Services* $0 copay for Medicare-covered Cardiac Rehabilitation Services
$0 copay for Medicare-covered Intensive Cardiac Rehabilitation Services
$0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services $0 copay for all preventive services covered under Original Medicare at zero cost-sharing
Plan covers a physical exam annually
Kidney Disease & Conditions $0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Outpatient Prescription Drugs $0 copay for Medicare-covered Part B chemotherapy drugs and other Part B drugs
Dental Services $0 copay for the following preventive dental benefits:
-2 oral exams every year
-2 cleanings every year
-2 flouride treatments every year
-1 dental X-ray every year
Plan offers additional supplemental Comprehensive dental benefits
$750 plan coverage limit for supplemental comprehensive dental benefits every year
$0 copay for Medicare-covered dental benefits
Hearing Services $0 copay for:
-1 supplemental hearing exam every year
-1 fitting-evaluation for supplemental hearing aid every year
-1 supplemental hearing aid every year
$0 copay Medicare-covered diagnostic hearing exams
$500 plan coverage for supplemental hearing aid every year
Vision Services $0 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye including an annual glaucoma screening for people at risk
$0 copay for:
-1 supplemental routine eye exam every year
-eyeglases
-contact lenses
$0 copay for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
$200 plan coverage limit for supplemental eyewear every year
Wellness Education and other Supplemental Benefits & Services Health Club membership
Nursing Hotline
Over-The-Counter Items $70 per quarter for OTC items
Transportation This plan does not cover supplemental routine transportation
Acupuncture & Other Alternative Therapies This plan does not cover Acupuncture and Other Alternative Therapies
Part D Prescription Drug Coverage
Annual Deductible $0
Tier 1 – One month supply Generic $0, $1.20 or $2.55 copay
Tier 2 – One month supply Preferred Brand $0, $3.60 or 6.35 copay
Tier 3 – One month supply Non-Preferred Brand $0, $3.60 or 6.35 copay
Tier 4 – One month supply Injectable $0, $3.60 or 6.35 copay

Last Updated: 03/20/2014    H5294_14Website_Approved_4/11/2014