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Health Alliance NW Companion POS Rx (HMO-POS)

3 out of 5 stars* for plan year 2024
$49.00 Monthly Premium

Health Alliance NW Companion POS Rx (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by The Carle Foundation

Plan ID: H3471-018-000

$49.00 Monthly Premium

Washington Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Washington Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage Details
Monthly plan premium$49.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$175.00
Out-of-pocket maximum$6,950.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $15.00
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40.00
Inpatient hospital careIn-Network:

Acute Hospital Services:
$500.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Prior Authorization Required for Acute Hospital Services
Urgent care
Urgent Care:
Copayment for Urgent Care $40.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $40.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $100.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100.00
Copayment for Worldwide Emergency Transportation $475.00
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $475.00

Air Ambulance:
Copayment for Air Ambulance Services $475.00

Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Health Alliance NW Companion POS Rx (HMO-POS) covers a range of additional benefits. Learn more about Health Alliance NW Companion POS Rx (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15.00
Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoring
POS (Out-of-Network):

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies and Services 30%
Durable medical equipment (DME)
POS (Out-of-Network):

Durable Medical Equipment:
Coinsurance for Medicare Covered Durable Medical Equipment 30%
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $20.00
Copayment for Medicare-covered Lab Services $20.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $375.00
Copayment for Medicare-covered Therapeutic Radiological Services $60.00
Copayment for Medicare-covered X-Ray Services $35.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Mental health inpatient care
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 30%
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Outpatient services/surgery
POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 30%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual or Group Sessions 20%
POS (Out-of-Network):

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual or Group Sessions 30%
Podiatry services
POS (Out-of-Network):

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 30%
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Dental careIn-Network:

Preventive Dental:
Maximum Plan Allowance of $250.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $50.00
Maximum Plan Allowance of $250.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Vision benefitsIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $25.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Hearing benefits
POS (Out-of-Network):

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 30%

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Preventive services and health/wellness education programsIn-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The Health Alliance NW Companion POS Rx (HMO-POS) offers prescription drug coverage, with an annual drug deductible of $175.00 (excludes Tiers 1 and 2)

    Coverage
    Cost
    Coverage & Cost
    Annual drug deductible$175.00 (excludes Tiers 1 and 2)
    Tier 1
  • Standard retail $2.00
  • Standard mail order $2.00
  • Tier 2
  • Standard retail $15.00
  • Standard mail order $15.00
  • Annual drug deductible$175.00 (excludes Tiers 1 and 2)
    Tier 1
  • Standard retail $4.00
  • Standard mail order $4.00
  • Tier 2
  • Standard retail $30.00
  • Standard mail order $30.00
  • Annual drug deductible$175.00 (excludes Tiers 1 and 2)
    Tier 1
  • Standard retail $6.00
  • Standard mail order $4.00
  • Tier 2
  • Standard retail $45.00
  • Standard mail order $30.00
  • When reviewing Washington Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

    You may be able to find plans in your part of Washington that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents

    Washington Counties Served

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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