The Medicare Advantage Dual (HMO SNP) plan offers added support for individuals who qualify for both Medicare Parts A and B and Apple Health (Medicaid) benefits.
- Up to $4,500 on preventive and comprehensive dental care
- Quarterly over-the-counter (OTC) benefit of up to $350
- 75 one-way rides to and from provider and pharmacy visits
Note: Your monthly plan premium may be paid for as long as you qualify for 100% Low Income Subsidy (“Extra Help”). Your Medicare Part B premium must continue to be paid, although that too may be paid for through these subsidies. Contact us to learn more: 1-800-942-0247 (TTY Relay: 711), 8 a.m. to 8 p.m., seven days a week.
Plan Benefits at a Glance
Coverage Includes: Medical, Vision, Dental, Prescription Drugs, Over-the-Counter benefits, Hearing Aid Supplement, Transportation, Fitness Program, and more.
Where This Plan is Offered: Adams, Benton, Chelan, Clallam, Clark, Cowlitz, Douglas, Franklin, Grant, Grays Harbor, Jefferson, King, Kitsap, Lewis, Mason, Okanogan, Pacific, Pierce, Skagit, Snohomish, Spokane, Stevens, Thurston, Walla Walla, Wahkiakum, Whatcom and Yakima counties.
|CHPW Medicare Advantage||Original Medicare|
|Pharmacy||Generic drugs: $0 to $3.95
Brand drugs: $0 to $9.85
|Vision||1 routine eye exam per year + up to $400 every 2 years for prescription vision hardware||Not Covered|
|Dental||$0 copay. Up to $4,500 per year for
preventative and comprehensive services.
|Hearing Aids||$0 copay exam and fitting. Up to $1,700 for hearing aids and supplies every year.||Not Covered|
|Podiatry||$0 copay. Up to 4 supplemental routine visits per year.||Not Covered|
|Alternative Medicine||$0 copay. Up to 12 visits per year. for acupuncture, naturopathy, and non-Medicare covered Chiropractic||Not Covered|
|Transportation||75 one-way rides per year to provider offices, medical centers, and pharmacies||Not Covered|
|Over the Counter Allowance (OTC)||$350 to spend on health products every 3 months, up to $1,400 per year||Not Covered|
|Fitness Program||Fitness kit and gym membership||Not Covered|
*Your monthly plan premium of $40.40 is paid for as long as you qualify for 100% Low Income Subsidy (“Extra Help”). For more information on Extra Help, see Chapter 2, section 7, of your Evidence of Coverage. Your Medicare Part B premium must continue to be paid, although that too may be paid for through these subsidies.
Covered Services & Cost
Evidence of Coverage
The Evidence of Coverage (EOC) provides plan details and payment information for services, including copays, coinsurance, limitation, prior authorizations, and deductibles.
Prescription drug formularies provide information about costs, restrictions, and other considerations related to the plan’s prescription medication coverage.
- Post-Discharge Meals
- Over-the-Counter Products
- Rides to Medical Visits
- Hearing Aids and Exam Coverage
- Dental Services
- Fitness Program
- Individualized case management
Providers and Care Facilities
Has Anything Changed for 2022?
Download the Annual Notice of Change (ANOC) to review any changes to the plan.