Select HMO-POS Special Needs Plan with Prescription Drug for Institutional Residents (2019)
The Select Advantage
- No Deductible Cost
$0 deductible for medical coverage
- Durable Medical Equipment (DME)
Covers medically necessary DME, such as walkers,
wheelchairs and low-loss air mattresses
- Physical, Occupational and Speech Therapy
No annual limit
- Skilled Nursing Care
No prior hospital stay requirement
- All-In-One Plan
Covers original Medicare benefits plus
Medicare Part D prescription drugs
|Summary of Important Costs|
|Primary Care Visit||$0 per visit|
|Specialist Visit||$35 per visit|
|Inpatient Hospital Stays||$0 deductible
$300 per day for days 1 – 5
$0 copay per day for days 6 – 90
|Part D Prescription Drugs||Standard Benefit
Coinsurance during the Initial Coverage Stage:
Preferred Generic $2.00
Preferred Brand $47.00
Non-Preferred Drug $100
Specialty Tier 33%
|Maximum out-of-pocket amount
(does not include prescription drugs)
Superior Select Medicare products are sold through licensed and appointed agents. The agent will complete a “Scope of Appointment” form and detail what would be discussed during the sales presentation. After that, the agent will go through the elements of the plan with specific focus on eligibility, service area, covered services and cost sharing.
Individuals who want to enroll after the presentation must complete a Superior Select Enrollment Form and return it to the agent for processing.
Once the enrollment form is processed, the new member will receive a welcome packet with a confirmation notice and the plan’s ID card along with a formulary, and provider and pharmacy directory information.
Coverage is generally effective the first of the following month, but not when enrollment is completed during this Annual Enrollment Period. Enrollment from October 15 through December effective January 1 of the following year.
Download 2019 Enrollment Form
Download 2018 Enrollment Form
Medicare Advantage Ending My Membership (Disenrollment)
Ending your membership in Superior Select Health Plans may be voluntary (your own choice) or involuntary (not your own choice):
- You might leave our plan because you have decided that you want to leave.
- There are only certain times during the year, or certain situations, when you may voluntarily end your membership in the plan.
- The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing.
- There are also limited situations where you do not choose to leave, but we are required to end your membership.
When can you end your membership in Superior Select Health Plans?
- You can end your membership during the Annual Enrollment Period (October 15 through December 7).
- You can end your membership during the annual Medicare Advantage Disenrollment Period (January 1 through February 14), but your choices are more limited.
- In certain situations, you can end your membership during a Special Enrollment Period.
For more information about ending your membership see Chapter 10 Section 2 of your Evidence of Coverage.
How do you end your membership in Superior Select Health Plans?
Usually, you end your membership by enrolling in another plan. For more information about how to end your membership see Chapter 10 Section 3 of your Evidence of Coverage.
Until your membership ends, you are still a member of our plan
If you leave Superior Select Health Plans, it may take time before your membership ends and your new Medicare coverage goes into effect. During this time, you must continue to get your medical care and prescription drugs through our plan.
- You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services.
- If you are hospitalized on the day that your membership ends, your hospital stay will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins).
Superior Select Health Plans may end your membership in the plan in certain situations
Tribute Health Plans must end your membership in the plan if any of the following happen:
- If you do not stay continuously enrolled in Medicare Part A and Part B. If you move out of our service area.
- If you are away from our service area for more than six months.
- If you move or take a long trip, you need to call Customer Service to find out if the place you are moving or traveling to is in our plan’s area.
- If you become incarcerated (go to prison).
- If you lie about or withhold information about other insurance you have that provides prescription drug coverage.
- If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
- If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
- If you let someone else use your membership card to get medical care. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)
- If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General.
- If you do not pay the plan premiums for 2 calendar months.
- We must notify you in writing that you have 2 calendar months to pay the plan premium before we end your membership.
- If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our plan and you will lose prescription drug coverage.
We cannot ask you to leave our plan for any reason related to your health. If you feel that you are being asked to leave our plan because of a health-related reason, you should call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may call 24 hours a day, 7 days a week.
You have the right to make a complaint if we end your membership in our plan. If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can make a complaint about our decision to end your membership.
For more information about how and when Superior Select Health Plans can end your membership see Chapter 10 Section 5 of your Evidence of Coverage. You can also contact Superior Select Health Plans at 1-877-372-1033 from 8 a.m. to 8 p.m. Monday through Friday. TTY users call 711.
Formulary – 2019
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