HAP Senior Plus (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$164.90	$0.00	$0.00	$0.00	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

HAP Senior Plus (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$0.00
Initial Coverage Limit:	$4,660.00
Catastrophic Coverage Limit:	$7,400.00
Drug Benefit Type:	Enhanced
Gap Coverage:	Yes
Formulary Link:	Formulary Link

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS 25%	LIS 50%	LIS 75%	LIS Full
$0.00	$43.40	$34.80	$26.30	$17.70

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1 (Preferred Generic)	$0.00 copay	$7.00 copay	$0.00 copay	$7.00 copay
2 (Generic)	$10.00 copay	$16.00 copay	$10.00 copay	$16.00 copay
3 (Preferred Brand)	$42.00 copay	$47.00 copay	$42.00 copay	$47.00 copay
4 (Non-Preferred Drug)	48%	50%	48%	50%
5 (Specialty Tier)	33%	33%	33%	33%
6 (Select Care Drugs)	$0.00 copay	$0.00 copay	$0.00 copay	$0.00 copay

60 Day

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1 (Preferred Generic)	$0.00 copay	$21.00 copay	$0.00 copay	$21.00 copay
2 (Generic)	$30.00 copay	$48.00 copay	$0.00 copay	$48.00 copay
3 (Preferred Brand)	$126.00 copay	$141.00 copay	$105.00 copay	$141.00 copay
4 (Non-Preferred Drug)	48%	50%	48%	50%
5 (Specialty Tier)
6 (Select Care Drugs)	$0.00 copay	$0.00 copay	$0.00 copay	$0.00 copay

Gap Coverage Phase

30 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
6 (Select Care Drugs)	$0.00 copay	$0.00 copay	$0.00 copay	$0.00 copay

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
6 (Select Care Drugs)	$0.00 copay	$0.00 copay	$0.00 copay	$0.00 copay

Tier	Cost
All other tiers (Generic)	25%
All other tiers (Brand-name)	25%

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

Drug Type	Cost Share
Generic drugs	$4.15 copay or 5% (whichever costs more)
Brand-name drugs	$10.35 copay or 5% (whichever costs more)

Additional Benefits

HAP Senior Plus (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-Network: No

Dental (comprehensive)

Diagnostic services:	Not covered (no limits)
Endodontics:	50% coinsurance (limits may apply) (authorization required) (referral not required)
Extractions:	50% coinsurance (limits may apply) (authorization required) (referral not required)
Non-routine services:	Not covered (no limits)
Periodontics:	$0 copay (limits may apply) (authorization required) (referral not required)
Prosthodontics, other oral/maxillofacial surgery, other services:	50% coinsurance (limits may apply) (authorization required) (referral not required)
Restorative services:	50% coinsurance (limits may apply) (authorization required) (referral not required)

Dental (preventive)

Cleaning:	$0 copay (limits may apply) (authorization not required) (referral not required)
Dental x-ray(s):	$0 copay (limits may apply) (authorization not required) (referral not required)
Fluoride treatment:	$0 copay (limits may apply) (authorization not required) (referral not required)
Oral exam:	$0 copay (limits may apply) (authorization not required) (referral not required)

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI):	$0-175 copay (authorization required) (referral not required)
Diagnostic tests and procedures:	$0-150 copay (authorization required) (referral not required)
Lab services:	$0 copay (authorization required) (referral not required)
Outpatient x-rays:	$35 copay (authorization required) (referral not required)

Doctor visits

Primary:	$0 copay
Specialist:	$40 copay per visit (authorization not required) (referral not required)

Emergency care/Urgent care

Emergency:	$90 copay per visit (always covered)
Urgent care:	$0-55 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment:	$0-40 copay (authorization not required) (referral not required)
Routine foot care:	Not covered

Ground ambulance

$275 copay

Health plan deductible

$0.00

Health plan deductibles (other)

In-Network: No

Hearing

Fitting/evaluation:	$0 copay (limits may apply) (authorization not required) (referral not required)
Hearing aids:	$689-2,039 copay (limits may apply) (authorization not required) (referral not required)
Hearing exam:	$0-40 copay (authorization not required) (referral not required)

Hospital coverage (inpatient)

$310 per day for days 1 through 6
$0 per day for days 7 through 90 (authorization required) (referral not required)

Hospital coverage (outpatient)

$250 copay per visit (authorization required) (referral not required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$4,500 In-network

Medical equipment/supplies

Diabetes supplies:	0-20% coinsurance per item (authorization not required)
Durable medical equipment (e.g., wheelchairs, oxygen):	20% coinsurance per item (authorization required)
Prosthetics (e.g., braces, artificial limbs):	20% coinsurance per item (authorization required)

Medicare Part B drugs

Chemotherapy:	20% coinsurance (authorization required)
Other Part B drugs:	20% coinsurance (authorization required)

Mental health services

Inpatient hospital – psychiatric:	$310 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral not required)
Outpatient group therapy visit:	$0 copay (authorization required) (referral not required)
Outpatient group therapy visit with a psychiatrist:	$0 copay (authorization required) (referral not required)
Outpatient individual therapy visit:	$0 copay (authorization required) (referral not required)
Outpatient individual therapy visit with a psychiatrist:	$0 copay (authorization required) (referral not required)

Optional supplemental benefits

Yes

Preventive care

$0 copay (authorization not required) (referral not required)

Rehabilitation services

Occupational therapy visit:	$20 copay (authorization required) (referral not required)
Physical therapy and speech and language therapy visit:	$20 copay (authorization required) (referral not required)

Skilled Nursing Facility

$0 per day for days 1 through 20
$196 per day for days 21 through 100 (authorization required) (referral not required)

Transportation

Not covered

Vision

Contact lenses:	$0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass frames:	$0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass lenses:	$0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglasses (frames and lenses):	$0 copay (limits may apply) (authorization not required) (referral not required)
Other:	Not covered (no limits)
Routine eye exam:	$0 copay (limits may apply) (authorization not required) (referral not required)
Upgrades:	Not covered

Wellness programs (e.g., fitness, nursing hotline)

Covered (authorization not required) (referral not required)

Optional Benefits

Package #1

Comprehensive dental:	Monthly Premium:	$46.60
Comprehensive dental:	Deductible:	N/A

Package #2

Comprehensive dental:	Monthly Premium:	$20.00
Comprehensive dental:	Deductible:	N/A

Package #3

Comprehensive dental:	Monthly Premium:	$39.30
Comprehensive dental:	Deductible:	N/A

Ready to sign up for HAP Senior Plus (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

HAP Senior Plus (HMO)

Locations

Plan Overview

Premium Breakdown

Drug Info

Part D Premium Reduction

Initial Coverage Phase

Gap Coverage Phase

Catastrophic Coverage Phase

Additional Benefits

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

Dental (comprehensive)

Dental (preventive)

Diagnostic procedures/lab services/imaging

Doctor visits

Emergency care/Urgent care

Foot care (podiatry services)

Ground ambulance

Health plan deductible

Health plan deductibles (other)

Hearing

Hospital coverage (inpatient)

Hospital coverage (outpatient)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

Medical equipment/supplies

Medicare Part B drugs

Mental health services

Optional supplemental benefits

Preventive care

Rehabilitation services

Skilled Nursing Facility

Transportation

Vision

Wellness programs (e.g., fitness, nursing hotline)

Optional Benefits

Package #1

Package #2

Package #3

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