Mary Washington Medicare Advantage Complete (HMO)
NO Deductibles
With Mary Washington Medicare Advantage, there are no additional premiums to pay for prescription drug coverage or extras like preventive dental and vision coverage. There are also no annoying deductibles to meet. Your coverage begins right away.
Complete Coverage With One Plan From One Company
Unlike Original Medicare plans, Mary Washington Medicare Advantage bundles your medical, hospital and prescription drug coverage together in one comprehensive plan.
Additionally, our plans come with a number of valuable extra benefits that will save you time and money.
$0 Copays on Generic Prescriptions
Save even more money on your prescription drugs when you fill your prescription at preferred pharmacies. Mary Washington Medicare Advantage Complete members can get generic Tier 1 and Tier 2 prescriptions for $0 copays and reduced copays on brand-name medications at any participating preferred pharmacy.
Important Travel Coverage
Whether you are making a trip out of the state or out of the country, we have you covered. If you ever get sick or injured when away from home, you can rest easy knowing you have emergency or urgent care coverage.
Important Financial Protection
Mary Washington Medicare Advantage protects your savings and retirement by putting an annual limit on what you have to pay out of your own pocket for your covered medical expenses—important protection not offered by Original Medicare plans.
Valuable Extra Benefits That Save You Money
Mary Washington Medicare Advantage Complete comes with important extra benefits for no additional premium such as preventive dental, vision, hearing, transportation to and from doctor appointments, free memberships to health clubs through the popular SilverSneakers® program, and coverage on over-the-counter products such as non-prescription drugs and health-related items.
Benefits at a Glance:
We’ve Got You Covered From Head to Toe
The following table highlights just some of the many benefits available to you as a valued Mary Washington Medicare Advantage member. For more details and a complete list of benefits, please review our Summary of Benefits or Evidence of Coverage which can be downloaded by clicking the links below.
Hospital & Medical Coverage
Your Mary Washington Medicare Advantage plan provides comprehensive medical and hospital coverage with no annual deductible and low copayments.
| Mary Washington Medicare Advantage Complete (HMO) | |
|---|---|
| Monthly Premium | $0 |
| Maximum Out-of-Pocket Limit | $3,400 Per Year |
| Annual Medical Deductible | $0 |
| Preventive Care/Screenings | $0 Copay |
| Primary Care Doctor Visists | $0 Copay |
| Specialty Care Doctor Visits | $40 Copay |
| Urgent Care | $35 Copay |
| Emergency Care | $125 Copay |
| Lab Services | $5 Copay |
| Home Healthcare | 100% Coverage |
| Chiropractic Services | $20 Copay |
| Inpatient Hospital Care | $275 Per Day for Days 1-6, $0 Per Day for Day 7 and Beyond |
| Outpatient Surgery at Hospital | $275 Copay |
| Outpatient Surgery at Ambulatory Surgery Center | $250 Copay |
Part D Drug Coverage
This table shows the drug tiers associated with your plan, and the copayments or co-insurance that you will pay in each tier. A drug formulary provides a list of drugs that are covered by our plan.
| Mary Washington Medicare Advantage Complete (HMO) | ||
|---|---|---|
| Preferred Pharmacies |
Other Network Pharmacies |
|
| Annual Part D Deductible | $0 | $0 |
| Tier 1 - Preferrred Generics | $0 Copay* | $4 Copay* |
| Tiier 2 - Generics | $0 Copay* | $12 Copay* |
| Tier 3 - Preferred Brands | $39 Copay* | $44 Copay* |
| Tier 4 - Non-Preferred Brands | $90 Copay* | $95 Copay* |
| Tier 5 - Specialty Drugs | 33% Co-insurance* | 33% Co-insurance* |
| Initial Coverage Limit | $4,660 Per Year | $4,660 Per Year |
All copay amounts shown are for a 30-day supply.
Insulin Coverage
You won’t pay more than $35 for a one-month supply of each Part D insulin product covered by our plan, no matter the cost-sharing tier of the insulin product, the prescription drug coverage stage you are in (initial coverage, coverage gap, or catastrophic coverage), your Extra Help status or whether the insulin product is considered a Select Insulin under the plan’s Prescription Drug Formulary.*
| Mary Washington Medicare Advantage Complete (HMO) | |
|---|---|
| Preferred Retail Cost-Sharing Tier 3 Select Insulins |
30-Day Supply: $35 copay 60-Day Supply: $70 copay 90-Day Supply: $105 copay |
| Standard Retail Cost-Sharing Tier 3 Select Insulins |
30-Day Supply: $35 copay 60-Day Supply: $70 copay 90-Day Supply: $105 copay |
| Standard Mail-Order Cost-Sharing Tier 3 Select Insulins |
30-Day Supply: $35 copay 60-Day Supply: $70 copay 90-Day Supply: $97.50 |
*Select Insulins are those that are part of the Insulin Savings Program and incur low, consistent copays through the coverage gap. Insulins administered via a durable medical equipment insulin pump are not included in the program. For information regarding which insulins are Select Insulins under the plan’s benefit, refer to the plan’s Prescription Drug Formulary. See the Evidence of Coverage for more information regarding Select Insulins, including full cost-sharing information. The program doesn’t apply during the catastrophic coverage stage, or if you receive Extra Help.
Extra Benefits
Your Mary Washington Medicare Advantage plan offers many valuable extras not offered by Original Medicare or Medicare supplement plans–at no additional cost to you.
| Mary Washington Medicare Advantage Complete (HMO) | |
|---|---|
| Vision Care | $0 Copay for routine eye exam |
| Preventive Dental Visits | $35 Copay |
| Over-the-Counter (OTC) Items | $60 Per Quarter |
| Hearing | $35 Copay for routine or Medicare-covered hearing exam |
| Telehealth | Video visits with PCPs and select specialists—same copay as in‑office visits |
| Transportation Assistance | $0 Copay for 20 one-way trips to approved locations per year |
| SilverSneakers® Fitness Benefits | SilverSneakers® included at no cost |
| Travel Coverage | Emergency or urgent care coverage if you are making a trip out of state or country |
Extra benefit expenses are not covered under the maximum out-of-pocket limit.
