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MercyOne Health Plan Glory No RX (HMO) - H3668-029-000
$0.00
Monthly Premium
MercyOne Health Plan Glory No RX (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Trinity Health
Plan ID: H3668-029-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Iowa 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 Iowa Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price. Speak with a licensed insurance agent to review plans available to you at 1-800-557-6059 (TTY 711,24/7).
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | -$1.00 |
| Out-of-pocket maximum | $4,500.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $25 |
| Inpatient hospital care | In-Network: Acute Hospital Services: $250 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $25 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $110 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 48 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $110 Copayment for Worldwide Emergency Transportation $200 to $250 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $200 Prior Authorization is required if outside Medicare benefit parameters. Air Ambulance: Copayment for Air Ambulance Services $250 Prior Authorization Required for Air Ambulance Prior Authorization is required for Non Emergency Fixed Wing, Rotary Wing ambulance services. |
Health Care Services and Medical Supplies
MercyOne Health Plan Glory No RX (HMO) covers a range of additional benefits. Learn more about MercyOne Health Plan Glory No RX (HMO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $20 Prior Authorization Required for Chiropractic Services Prior Authorization is required if exceeds Medicare benefit limits. |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior Authorization is required for Power Mobility Devices. |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $20 Copayment for Medicare-covered Lab Services $0 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Prior Authorization is required for Oncology Services and Genetic testing. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $150 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $250 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $20 Copayment for Medicare-covered Group Sessions $20 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $275 The minimum cost share applies to services received in Coumadin Clinics. The Specialist Services cost share applies to services received in Respiratory Therapy Departments or other Outpatient Hospital Service Departments not otherwise noted in an alternative PBP benefit category. The maximum cost share applies to Outpatient Hospital Surgery Department services.If multiple outpatient services are received from the same provider on the same date, the service with the highest copayment will apply for that day.There is no copayment for outpatient observation stays, however, a copayment does apply for outpatient services rendered during the observation stay. The outpatient service with the highest copayment will apply each day. Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $275 |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $20 Copayment for Medicare-covered Group Sessions $20 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
|
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $25 |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 55 $0 per day for days 56 to 100 Notification will be required within two days of admission. |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Copayment for Medicare-Covered Services $25 Preventive Dental: Copayment for Preventive Dental $0; includes the following services:
Comprehensive Dental: Coinsurance for Restorative Services 50% Coinsurance for Endodontics 70% Coinsurance for Periodontics 70% Coinsurance for Oral and Maxillofacial Surgery (Extractions) 50% Copayment for Adjunctive General Services $0 Maximum Plan Benefit of $1,000 every year |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $25 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $200 every year |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $25 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $399 per ear for TruHearing Advanced, $699 per ear for TruHearing Premium
|
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 programs | In-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:
Yearly "Wellness" visit |
When reviewing Iowa 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 Iowa 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 |
Iowa Counties Served
- Adair
- Adams
- Appanoose
- Benton
- Black Hawk
- Boone
- Bremer
- Buchanan
- Butler
- Cedar
- Cerro Gordo
- Cherokee
- Chickasaw
- Clarke
- Clayton
- Clinton
- Dallas
- Delaware
- Fayette
- Floyd
- Franklin
- Greene
- Grundy
- Guthrie
- Hamilton
- Hancock
- Hardin
- Henry
- Humboldt
- Ida
- Jackson
- Jasper
- Jones
- Keokuk
- Kossuth
- Louisa
- Lucas
- Madison
- Mahaska
- Marion
- Mitchell
- Monona
- Monroe
- Muscatine
- Plymouth
- Polk
- Poweshiek
- Ringgold
- Scott
- Sioux
- Tama
- Union
- Warren
- Wayne
- Winnebago
- Woodbury
- Worth
- Wright
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.