MA Plan 4 (HMO)

Local Care for an Affordable Premium

The Medicare Advantage Plan 4 covers medical, dental, vision, and prescription drugs for an affordable monthly premium.

You also get extra benefits that support your whole health—like acupuncture and routine chiropractic.

Where Is This Plan Offered?

Adams, Chelan, Douglas, Grant, Lewis, Okanogan, Skagit, Walla Walla, Whatcom, and Yakima counties.

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Call 1-800-944-1247 (TTY: 711) Enroll Now
7 days a week, 8 a.m. to 8 p.m.

Extra Benefits at a Glance

Coverage Includes: Dental, Vision, Prescription Drugs, Fitness Program, and more.

	CHPW Medicare Advantage	Original Medicare
Premium	$105*	Part B Premium
Pharmacy	5 Tiers (1/2/3/4/5) Preferred: $0/$10/$37/50%/33% Standard: $10/$20/$47/50%/33%	Not Covered
Vision	1 routine eye exam plus up to $150 every two years for glasses or contacts. Choose from a wide network of vision providers.	Not Covered
Dental	$500 a year for comprehensive services and unlimited preventive. Choose from a large network of dentists.**	Not Covered
Podiatry	$0 copay. Up to 4 visits per year for non-Medicare covered foot care from a Medicare-approved foot care provider.	Not Covered
Health and Wellbeing	Combined total of 12 visits a year for acupuncture, naturopathy, and chiropractic.	Not Covered
Fitness Program	Fitness kit, gym membership.	Not Covered

*You must continue to pay your Medicare Part B premium.

**You must use a dentist who is part of Delta Dental of Washington’s dental network. To find the most current listing of Delta Dental PPO Plus Premier network dentists, visit DeltaDentalWA.com.

Download documents

Covered Services & Cost

	Special Benefits Fitness Program Post-Discharge Meals Health and Wellbeing Personalized case management
	Prescription Coverage Our list of covered drugs (also called a formulary) provides information about costs, restrictions, and other important details related to a plan’s prescription medication coverage.
	Providers and Care Facilities Use our Find a Doctor tool or browse our provider directories to find primary care providers, vision providers, specialists, care facilities, and pharmacies in our network.
	Evidence of Coverage The Evidence of Coverage (EOC) | Evidencia de cobertura (EOC) provides plan details and payment information for services, including copays, coinsurance, limitation, prior authorizations, and deductibles.

Has Anything Changed for 2024?

Download the 2024 Annual Notice of Change (ANOC) to review any changes to the plan:
Annual Notice of Change 2024 | Aviso anual de cambios para 2024

Questions?

Call us at 1-800-944-1247 (TTY: 711). Our licensed Medicare experts will help you over the phone. We’re here for you 7 days a week, from 8 a.m. to 8 p.m.