2022 MyTruAdvantage Select (HMO)

The amount you’ll pay for most covered in-network medical services before you start paying only copayments or coinsurance and MyTruAdvantage pays the balance.

This is the most you pay during a calendar year for in-network and out-of-network services before MyTruAdvantage begins to pay 100% of the allowed amount. This limit includes copayments and coinsurance payments. It does not include your monthly premium or Part D drug costs.

for each visit

Includes Ambulatory Surgical Center, Outpatient hospital and Observation Visits.

Each service

Includes immunizations, physical exams (initial exam and annual wellness visit), colorectal screening, pap smears and pelvic exams screening, prostate cancer screening, bone mass measurement, mammography screening, and outpatient hospital services - preventive

Each service

Each service

Each service

Each service

This includes what you pay for radiology/imaging services such as a CT scan or MRI

Each service

up to one per year

Routine hearing services must be provided by a TruHearing provider.

Depending on the type

Each service

Cleanings & exams (2 per year), and bitewing x-rays (one per year). 50% of the cost for fillings, crown repairs, brush biopsy, relines, and repairs to bridges and dentures.

Each exam

Routine vision services must be provided by an "Eyemed Select" provider.

Annual benefit amount

Each day, Days 1-5/days 6-90

Each visit

Each day, Days 1-20/Days 21-100

This plan covers up to 100 days each benefit period

Each visit

Each trip, Ground/air

Every 3 months

The OTC benefit offers you an easy way to get generic over-the-counter health and wellness products by phone at 1-888-628-2770 (TTY: 711) or online at www.cvs.com/otchs/MyTruAdvantage. You order from a list of approved OTC items, and OTC Health Solutions will mail them directly to your home address.

Includes a no-cost gym membership at a participating fitness center or YMCA, one Stay Fit Kit (options include a Fitbit, Garmin, yoga, or strength kit), and 2 home fitness kits, where you can choose from 34 options like Aqua, Tai Chi, Chair-based exercise and more.

For all tiers

Tier 1 (Preferred Generic), Tier 2 (Generic), Tier 3 (Preferred Brand), Tier 4 (Non-Preferred Drug), Tier 5 (Specialty Tier)

You pay the following until your total yearly drug costs reach $4430. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. Once you reach that amount, you will enter the Coverage Gap. You may get your drugs at network retail pharmacies and mail order pharmacies. During this stage, your out-of-pocket costs for Select Insulins will be $35 for a one-month (30-day) supply.

Preferred and standard retail (30-day)

When you reach your total yearly drug cost (which includes what our plan has paid and what you have paid) of $4430, you'll enter what is called a coverage gap. At this time, you wil pay 25% of the plan's cost for covered generic drugs and 25% of the plan's cost for covered brand drugs, plus dispensing fee, until your total costs reach $7050.

Most Medicare plans have this coverage gap (also called the "donut hole"), but not everyone will enter the coverage gap. During this stage, your out-of-pocket costs for Select Insulins will be $35 for a one-month (30-day) supply

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7050, you pay the greater of: 5% of the cost, or $3.95 copay for generic (including brand drugs treated as generic) and a $9.85 copay for all other drugs