Univera SeniorChoice Value (HMO) - Univera Prospect

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Univera SeniorChoice Value (HMO)

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For Coverage January 1, to December 31,

Plan Features

  • Robust provider network1
  • No referrals required
  • $0 copay for all Tier 1 Preferred Generic drugs
  • For a 90-day supply, you pay 2 times the copayment for a 30-day supply of your prescription
  • Coverage for preventive dental care including 2 oral exams, 2 cleanings, and 2 x-rays per year2
  • $75 annual eyewear allowance
  • Worldwide urgent care and emergency coverage
  • Silver&Fit® Fitness Program
    • $25 annual non-refundable fee to enroll in a participating fitness club or exercise center;
    • $10 annual non-refundable fee to enroll in the home fitness program; or
    • $150 annual allowance for out-of-network facilities.

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Benefits3

Medical Coverage
Univera SeniorChoice Value (HMO) provides comprehensive coverage for the health care services you need, including:

  • $10 copay per visit for primary care providers
  • $45 copay per visit for specialists
  • $0 copay for many Medicare-covered preventive services, such as physical exams, smoking cessation and some immunizations
  • $7 copay for in-network chiropractic medical visits
  • Inpatient Hospital Stay
    • $360 copay per day for days 1-5 for each Medicare-covered stay at a network hospital
    • Days 6+ covered in full
  • $6,700 annual Out-of-Pocket Maximum Protection (In-network services)

Prescription Drug Coverage4
Our prescription drug coverage features:

Tier 30-Day Supply 90-Day Supply
Tier 1 Preferred Generic Drugs $0 $0
Tier 2 Generic Drugs $10 $20
Tier 3 Preferred Brand Drugs $47 $94
Tier 4 Non-Preferred Drugs $100 $200
Tier 5 Specialty Drugs 33% 33%

 

  • $0 annual deductible (this is the amount you must pay for prescriptions before we begin to pay)
  • Additional savings when you take advantage of our mail order and select retail pharmacies that provide lower cost-sharing for a 90-day supply of your prescription drug(s)
  • The 5-Tier comprehensive formulary includes Tier 1, 2, 3, 4 and 5 drugs. Follow this link to Search for a Medication and View Drug Tier and Copayment or Coinsurance Information
  • Our nationwide network includes thousands of participating pharmacies. Additionally, Univera Healthcare has contracts with pharmacies that equal or exceed the CMS requirements for pharmacy access in your area

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Learn more with these resources:

1 Network Coverage Information - With our Medicare Advantage Health Maintenance Organization (HMO) plans you must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from Out-of-Network providers neither Medicare nor Univera Healthcare will be responsible for the costs. For information on how to request reimbursement for Out-of-Network claims from emergency, urgent or other services, or Coverage Determinations and Appeals call Customer Care at 1-877-883-9577, Monday - Friday, 8 a.m. to 8 p.m.; From October 1 through March 31, 8 a.m. to 8 p.m., 7 days a week (TTY/TDD 1-800-421-1220). Or, see the Evidence of Coverage using the link above. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

2 For out-of-network providers, we will pay 100% of the allowance or dentist charges, whichever is less. You will be responsible for the balance.

3 This information is not a complete description of benefits. Call 1-844-596-0345 (TTY/TDD 1-800-421-1220) for more information.

4 Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

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Visit our Resource Center at
205 Park Club Lane
Buffalo, NY 14221 Hours

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Need Help?

Speak with one of our dedicated Medicare Sales Advisors.
Call: 1-844-596-0345
TDD/TTY: 1-800-421-1220

Monday - Friday:
8 a.m. to 8 p.m.

From Oct. 1 - Mar. 31:
advisors are also available weekends 8 a.m. to 8 p.m.


Call Customer Service toll-free at 1-877-883-9577 (TTY/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Mar. 31, representatives also are available weekends from 8 a.m. to 8 p.m.

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Univera Healthcare contracts with the Federal Government and is an HMO plan with a Medicare contract. Enrollment in Univera Healthcare depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_5968_M.

This page last updated 08-03-2019.

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