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Talk to a licensed insurance agent at

1-800-782-5068

(TTY: 711).

PPO Plan Highlights for North Texas

STAR ratings:

This plan is too new to be measured.

Every year, Medicare evaluates plans based on a 5-star rating system.

Highlights of SeniorCare Advantage PPO for North Texas, and some popular options, are listed below for your convenience. This plan includes Part D Prescription Drug Coverage. For more details, please see the plan documents.

Please note:

  • With Advantage Medicare plans, you must continue to pay Medicare Part B premium, see benefit documents for more details.

  • At Scott and White Health Plan, you do not have to select a PCP to direct your care with SeniorCare Advantage PPO plan. You can see a specialist without a referral.

  • This is a Network Cost Sharing Plan. To help maximize SeniorCare Advantage PPO for North Texas benefits, use in-network providers for care; out-of-network cost-sharing for the PPO is 35%. There is a $750 deductible and $10,000 out-of-pocket maximum for services received out-of-network.

Find Provider(s) for this plan with our Find a Provider tool.

Find your prescription drug(s) for all SWHP Medicare plans in the Drug List Formulary (Updated: 9/1/2018).

Plan Highlights Sections

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  • Medical Plan Benefits*
    (must continue to pay Medicare Part B premium, see benefit documents for more details)
  • Monthly Premium with Part D prescription drug coverage
    (in-network)
  • HMO only - Monthly Premium without Part D prescription drug coverage
    (in-network)
  • Deductible
  • Out-of-Pocket Maximum
    (in-network)
  • Primary Care Physician (PCP) Office Visit
  • Specialist Office Visit
  • Diagnostic Tests, X-rays, Lab Services
    (separate office visit copay may apply)
  • Advanced Diagnostic Imaging Services
    (MRI, MRA, SPECT, CTA, CT, PET, Nuclear Cardiology)
  • Physical/ Occupational/ Speech Therapy
    (per visit)
  • Inpatient Hospital
  • Inpatient Mental Health
  • Skilled Nursing Facility (SNF)
  • Outpatient Surgery
    (facility)
  • Ambulatory Surgical Center
    (facility)
  • Ambulance
  • Emergency Care
    (U.S. only; copay waived if admitted within 24 hours)
  • Urgent Care
    (U.S. only; copay waived if admitted within 24 hours)
  • Durable Medical Equipment (DME)
  • PPO for North Texas
    Network Cost Sharing
  • $41
  • --
  • $0
  • $6,200
  • $0
    copay
  • $40
    copay
  • $0-$75
    copay
  • $300
    copay
  • $25
    copay
  • Days 1-5: $350/day;
    Days 6-90: $0/day
  • Days 1-5: $318/day;
    Days 6-90: $0/day
  • Days 1-20: $0/day;
    Days 21-100: $167.50/day
  • $350
    copay
  • $250
    copay
  • $350
    copay
  • $90
    copay
  • $50
    copay
  • 20%
    coinsurance
  • PPO Basic for Central Texas
    Network Cost Sharing
  • $43
  • --
  • $0
  • $6,200
  • $0
    copay
  • $40
    copay
  • $0-$75
    copay
  • $300
    copay
  • $25
    copay
  • Days 1-5: $350/day;
    Days 6-90: $0/day
  • Days 1-5: $318/day;
    Days 6-90: $0/day
  • Days 1-20: $0/day;
    Days 21-100: $167.50/day
  • $350
    copay
  • $275
    copay
  • $350
    copay
  • $90
    copay
  • $50
    copay
  • 20%
    coinsurance
  • PPO Platinum for Central Texas
    Network Cost Sharing
  • $150
  • --
  • $0
  • $3,500
  • $0
    copay
  • $20
    copay
  • $0-$20
    copay
  • $200
    copay
  • $25
    copay
  • Days 1-5: $200/day;
    Days 6-90: $0/day
  • Days 1-5: $200/day;
    Days 6-90: $0/day
  • Days 1-20: $0/day;
    Days 21-100: $50/day
  • $100
    copay
  • $75
    copay
  • $75
    copay
  • $90
    copay
  • $50
    copay
  • 20%
    coinsurance
  • HMO Select for Central Texas
  • $0
  • $0
  • $0
  • $5,300
  • $0
    copay
  • $40
    copay
  • $0-$75
    copay
  • $300
    copay
  • $25
    copay
  • Days 1-5: $350/day;
    Days 6-90: $0/day
  • Days 1-5: $318/day;
    Days 6-90: $0/day
  • Days 1-20: $0/day;
    Days 21-100: $167.50/day
  • $350
    copay
  • $275
    copay
  • $265
    copay
  • $80
    copay
  • $50
    copay
  • 20%
    coinsurance
  • HMO Preferred for Central Texas
  • $130
  • $90
  • $0
  • $3,400
  • $15
    copay
  • $15
    copay
  • $15
    copay
  • $15
    copay
  • $15
    copay
  • $450/stay
  • $450/stay
  • Days 1-20: $0/day;
    Days 21-100: $35/day
  • $15
    copay
  • $100
    copay
  • $75
    copay
  • $120
    copay
  • $40
    copay
  • 20%
    coinsurance
  • HMO Premium for Central Texas
  • $240
  • $199
  • $0
  • $3,400
  • $0
    copay
  • $0
    copay
  • $0
    copay
  • $0
    copay
  • $0
    copay
  • $0
    copay
  • $0
    copay
  • Days 1-20: $0/day;
    Days 21-100: $15/day
  • $0
    copay
  • $0
    copay
  • $40
    copay
  • $120
    copay
  • $40
    copay
  • $0
    copay
  • Prescription Drug Benefits
  • Initial Coverage Amount
  • Deductible
  • Deductible Applies to:
    Copays During Initial Coverage Period
  • Tier 1 — Preferred Generic Drugs
  • Tier 2 — Generic Drugs
  • Tier 3 — Preferred Brand Drugs
  • Tier 4 — Non-Preferred Drugs
  • Tier 5 — Specialty Drugs
  • After Initial Coverage Amount — You Pay
  • Preferred Generic Drugs
  • Other Generic Drugs
  • Brand-Name Drugs
  • Total Out-of-Pocket You Pay Before Catastrophic Coverage
  • Catastrophic Coverage Amounts — You Pay
  • PPO for North Texas
  • $3,820
  • $300
  • Tiers 3-5
  • $4
    copay
  • $14
    copay
  • $47
    copay
  • $99
    copay
  • 27%
    coinsurance
  • 37%
    coinsurance
  • 37%
    coinsurance
  • 25%
    coinsurance
  • $5,100
  • The greater of 5% or $3.40 for generic drugs (including brand drugs treated as generic) or $8.50 for all other drugs.
  • PPO Basic for Central Texas
  • $3,820
  • $250
  • Tiers 3-5
  • $3
    copay
  • $14
    copay
  • $47
    copay
  • $99
    copay
  • 28%
    coinsurance
  • 37%
    coinsurance
  • 37%
    coinsurance
  • 25%
    coinsurance
  • $5,100
  • The greater of 5% or $3.40 for generic drugs (including brand drugs treated as generic) or $8.50 for all other drugs.
  • PPO Platinum for Central Texas
  • $3,820
  • $0
  • All Tiers (1-5)
  • $0
    copay
  • $10
    copay
  • $40
    copay
  • $90
    copay
  • 33%
    coinsurance
  • $0
    copay
  • 37%
    coinsurance
  • 25%
    coinsurance
  • $5,100
  • The greater of 5% or $3.40 for generic drugs (including brand drugs treated as generic) or $8.50 for all other drugs.
  • HMO Select for Central Texas
  • $3,820
  • $300
  • Tiers 3-5
  • $6
    copay
  • $20
    copay
  • $47
    copay
  • $100
    copay
  • 27%
    coinsurance
  • 37%
    coinsurance
  • 37%
    coinsurance
  • 25%
    coinsurance
  • $5,100
  • The greater of 5% or $3.40 for generic drugs (including brand drugs treated as generic) or $8.50 for all other drugs.
  • HMO Preferred for Central Texas
  • $3,820
  • $100
  • Tiers 3-5
  • $3
    copay
  • $15
    copay
  • $45
    copay
  • $95
    copay
  • 31%
    coinsurance
  • 37%
    coinsurance
  • 37%
    coinsurance
  • 25%
    coinsurance
  • $5,100
  • The greater of 5% or $3.40 for generic drugs (including brand drugs treated as generic) or $8.50 for all other drugs.
  • HMO Premium for Central Texas
  • $3,820
  • $50
  • Tiers 3-5
  • $2
    copay
  • $12
    copay
  • $45
    copay
  • $95
    copay
  • 32%
    coinsurance
  • $4
    copay
  • 37%
    coinsurance
  • 25%
    coinsurance
  • $5,100
  • The greater of 5% or $3.40 for generic drugs (including brand drugs treated as generic) or $8.50 for all other drugs.
  • Bonus Benefits
  • Routine Eye Exam
    (one per year; must use a Superior Vision provider)
  • Eyewear
    (must use a Superior Vision provider)
  • Routine Hearing Exam
    (one per year)
  • Hearing Aids
  • Gym/Fitness Club Membership
    (at participating Silver&Fit locations)
  • Dental
    (must use MetLife PDP Plus network)
  • PPO for North Texas
  • $0
    copay
  • $125
    annual allowance toward purchase
  • $0
    copay
  • $1,000
    allowance toward purchase every 3 years
  • $0
  • $20 additional premium required
    $2,000 maximum benefit per year
  • PPO Basic for Central Texas
  • $0
    copay
  • $125
    annual allowance toward purchase
  • $40
    copay
  • $1,000
    allowance toward purchase every 3 years
  • $0
  • $20 additional premium required
    $2,000 maximum benefit per year
  • PPO Platinum for Central Texas
  • $0
    copay
  • $125
    annual allowance toward purchase
  • $20
    copay
  • $1,000
    allowance toward purchase every 3 years
  • $0
  • Included
    $1,500 maximum benefit per year
  • HMO Select for Central Texas
  • $0
    copay
  • $125
    annual allowance toward purchase
  • $40
    copay
  • $1,000
    allowance toward purchase every 3 years
  • $0
  • Included
    $1,500 maximum benefit per year
  • HMO Preferred for Central Texas
  • $0
    copay
  • $125
    annual allowance toward purchase
  • $15
    copay
  • Not Covered
  • $0
  • Included
    $1,500 maximum benefit per year
  • HMO Premium for Central Texas
  • $0
    copay
  • $125
    annual allowance toward purchase
  • $0
    copay
  • $1,000
    allowance toward purchase every 3 years
  • $0
  • Included
    $1,500 maximum benefit per year
  • Dental Benefits
    (Must use MetLife PDP Plus network)
  • Monthly Premium
  • Yearly Benefit Maximum
  • Deductible
  • Oral Exams
    (every 6 months)
  • Dental X-rays
    (every 3 years)
  • Extractions and Fillings
  • Dentures
    (every 5 years)
  • PPO for North Texas
  • $20
  • $2,000
  • $0
  • $0
  • $0
  • 50%
  • 50%
  • HMO Basic for Central Texas
  • $20
  • $2,000
  • $0
  • $0
  • $0
  • 50%
  • 50%
  • HMO Platinum for Central Texas
  • Included
  • $1,500
  • $0
  • $0
  • $0
  • 50%
  • 50%
  • HMO Select for Central Texas
  • Included
  • $1,500
  • $0
  • $0
  • $0
  • 50%
  • 50%
  • HMO Preferred for Central Texas
  • Included
  • $1,500
  • $0
  • $0
  • $0
  • 50%
  • 50%
  • HMO Premium for Central Texas
  • Included
  • $1,500
  • $0
  • $0
  • $0
  • 50%
  • 50%

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Have any questions?

Need language assistance?

Call Sales

Talk to a licensed insurance agent at

1-800-782-5068

(TTY: 711).

Plan Forms and Documents

View Printable Plan documents in PDF format. (May require free Adobe Acrobat Reader to view documents.)

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This information is not a complete description of benefits. Call 1-800-782-5068 (TTY: 711) for more information.

Out-of-network/non-contracted providers are under no obligation to treat plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services.

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