Select Health Medicare Kroger (HMO) is a Medicare Advantage Plan by Select Health.
This page features plan details for 2024 Select Health Medicare Kroger (HMO) H1994 – 023 – 0 available in Ada, Canyon, Cassia and Twin Falls Counties.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Select Health Medicare Kroger (HMO) is offered in the following locations.
Select Health Medicare Kroger (HMO) offers the following coverage and cost-sharing.
Insurer: | Select Health |
Health Plan Deductible: | $0.00 |
MOOP: | $4,500 In-network |
Drugs Covered: | Yes |
Ready to sign up for Select Health Medicare Kroger (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
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$174.70 | $0.00 | $0.00 | $0.00 | $ |
Select Health Medicare Kroger (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $100.00 |
Initial Coverage Limit: | $5,030.00 |
Catastrophic Coverage Limit: | $8,000.00 |
Drug Benefit Type: | Enhanced Alternative |
Additional Gap Coverage: | Yes |
Formulary Link: | Formulary Link |
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 Full |
---|---|
$0.00 | $ |
After you pay your $100.00 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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $0.00 copay | $0.00 copay | |
2 (Generic) | $5.00 copay | $10.00 copay | $0.00 copay | |
3 (Preferred Brand) | $40.00 copay | $47.00 copay | $40.00 copay | |
4 (Non-Preferred Drug) | $90.00 copay | $100.00 copay | $90.00 copay | |
5 (Specialty Tier) | 31% | 31% | 31% |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | ||||
2 (Generic) | ||||
3 (Preferred Brand) | ||||
4 (Non-Preferred Drug) | ||||
5 (Specialty Tier) |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $0.00 copay | $0.00 copay | |
2 (Generic) | $15.00 copay | $30.00 copay | $0.00 copay | |
3 (Preferred Brand) | $120.00 copay | $141.00 copay | $120.00 copay | |
4 (Non-Preferred Drug) | $270.00 copay | $300.00 copay | $270.00 copay | |
5 (Specialty Tier) |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) * | $0.00 copay | $0.00 copay | $0.00 copay | |
2 (Generic) * | $5.00 copay | $10.00 copay | $0.00 copay | |
Generic drugs | ||||
Brand-name drugs |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) * | $0.00 copay | $0.00 copay | $0.00 copay | |
2 (Generic) * | $15.00 copay | $30.00 copay | $0.00 copay | |
Generic drugs | ||||
Brand-name drugs |
Tier | Cost |
---|---|
All other tiers (Generic) | 25% |
All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.
Select Health Medicare Kroger (HMO) also provides the following benefits.
$0 |
In-network | No |
$4,500 In-network |
No |
In-network | No |
$0-250 copay or 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
Primary | $0 copay (Not applicable.) (Not applicable.) |
Specialist | $20 copay per visit (Authorization is not required.) (Referral is not required.) |
$0 copay (Authorization is not required.) (Referral is not required.) |
Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
Urgent care | $40 copay per visit (always covered) (Not applicable.) (Not applicable.) |
Diagnostic tests and procedures | $0-20 copay or 0-20% coinsurance (Authorization is required.) (Referral is not required.) |
Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
Diagnostic radiology services (e.g., MRI) | $0-250 copay (Authorization is required.) (Referral is not required.) |
Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
Hearing exam | $20 copay (Authorization is not required.) (Referral is not required.) |
Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Hearing aids | $699-2,399 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
Restorative services | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
Prosthodontics, other oral/maxillofacial surgery, other services | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Other | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Occupational therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
Physical therapy and speech and language therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
$250 copay (Not applicable.) (Not applicable.) |
Not covered (Not applicable.) (Not applicable.) |
Foot exams and treatment | $20 copay (Authorization is not required.) (Referral is not required.) |
Routine foot care | $20 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
Covered (Authorization is not required.) (Referral is not required.) |
Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
$300 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
Inpatient hospital – psychiatric | $300 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
Outpatient group therapy visit with a psychiatrist | $15 copay (Authorization is not required.) (Referral is not required.) |
Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
Outpatient group therapy visit | $15 copay (Authorization is not required.) (Referral is not required.) |
Outpatient individual therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
$0 per day for days 1 through 20 $203 per day for days 21 through 55 $0 per day for days 56 through 100 (Authorization is required.) (Referral is not required.) |
Ready to sign up for Select Health Medicare Kroger (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
Need more information on Select Health Medicare Kroger (HMO)? See 2025 Select Health Medicare Kroger (HMO) at MedicareAdvantageRX.com.
Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.
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SMID: MULTIPLAN_HCIHNDOGMED01PY25_M
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