PUP Rewards (HMO) H5696-002

This plan is available in Polk County, FL.

Quick Summary

PUP Rewards (HMO) H5696-002 Plan Details Apply Now

Plan
Premium		 Part B
Rebate		 Annual
Deductible		 Max. Out-
of-Pocket		 Doctor
Visits		 Hospital
Stays
$0 $67.00 $0 $4,200 PCP: $0
Specialist: $20  		Days 1-4: $130/day
Days 5-90: $0/day

Prescription Drug Coverage

Tier 1 Month 3 Months,
Mail Order 		3 Months,
In-Network Pharmacy
Tier 1
Preferred Generic 		$2 $2 $4
Tier 2
Non-Preferred Generic 		$4 $8 $10
Tier 3
Preferred Brand 		$40 $80 $100
Tier 4
Non-Preferred Brand 		$95 $285 $285
Tier 5
Specialty 		33% coinsurance

Urgent Care

  • $10 co-pay

Silver Sneakers Nationwide Gym Membership

  • $0 co-pay

Vision Care

  • $10 co-pay for:
    • up to 1 pair of eyeglasses or contact lenses after cataract surgery
    • up to 1 pair of glasses every year
    • up to 1 pair of contacts every year
  • $40 co-pay for exams to diagnose and treat diseases and conditions of the eye
  • $20 co-pay for up to 1 supplemental routine eye exam every year
  • $200 plan coverage limit for eyewear every year

Hearing Services

  • $0 co-pay for up to 1 hearing aid(s) every year
  • $40 co-pay for Medicare-covered diagnostic hearing exams
  • $10 co-pay for up to 1 supplemental routine hearing exam every year
  • $10 co-pay for up to 1 hearing aid(s) fitting-evaluation every year
  • $500 plan coverage limit for hearing aid(s) every year

Dental Services

  • $0 co-pay for the following preventive dental benefits:
    • up to 2 oral exams every year
    • up to 2 cleanings every year
    • up to 2 fluoride treatments every year
    • up to 1 dental X-ray every year
  • 0% of the cost for Medicare-covered dental benefits
  • $500 plan coverage limit for comprehensive dental benefits every year

Enhanced Drug Coverage

  • Viagra and Levitra are covered for the treatment of sexual or erectile dysfunction. You pay the Tier 3 (Preferred Brand) co-pay for these drugs. Quantity limits apply, up to 10 pills per month.

Plan Documents