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2023 Covenant Advantage (HMO-POS) Plans in Your Area

2023 Covenant Advantage
(HMO-POS)		 2023 Covenant Advantage Plus
(HMO-POS)
Medical & Hospital
Monthly Premium $0 $25
Maximum Out-of-Pocket Limit $3,600 Per Year $3,600 Per Year
Annual Deductible $0 $0
Preventive Care/Screenings $0 Copay $0 Copay
Primary Care Physician Visits $0 Copay $0 Copay
Specialist Doctor Visits $30 Copay $30 Copay
No referrals for in-network specialist visits!*
Urgent Care $60 Copay $60 Copay
Emergency Care $90 Copay $90 Copay
Lab Services $10 Copay $10 Copay
Home Health Care 100% Coverage 100% Coverage
Chiropractic Care $20 Copay $20 Copay
Inpatient Hospital $200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond		 $200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
Outpatient Surgery at Hospital $150 Copay $150 Copay
Outpatient Surgery at Ambulatory Surgery Center $100 Copay $100 Copay
Part D Prescription Drug Coverage
Annual Deductible
  • Preferred Pharmacies - $0
  • Other Network Pharmacies - $0
  • Preferred Pharmacies - $0
  • Other Network Pharmacies - $0
Tier 1
Preferred Generic
  • Preferred Pharmacies - $0 Copay*
  • Other Network Pharmacies - $5 Copay*
  • Preferred Pharmacies - $0 Copay*
  • Other Network Pharmacies - $5 Copay*
Tier 2
Non-Preferred Generics
  • Preferred Pharmacies - $0 Copay*
  • Other Network Pharmacies - $10 Copay*
  • Preferred Pharmacies - $0 Copay*
  • Other Network Pharmacies - $10 Copay*
Tier 3
Preferred Brand Names
  • Preferred Pharmacies - $40 Copay*
  • Other Network Pharmacies - $45 Copay*
  • Preferred Pharmacies - $40 Copay*
  • Other Network Pharmacies - $45 Copay*
Tier 4
Non-Preferred Brand Names
  • Preferred Pharmacies - $90 Copay*
  • Other Network Pharmacies - $95 Copay*
  • Preferred Pharmacies - $90 Copay*
  • Other Network Pharmacies - $95 Copay*
Tier 5
Specialty Drugs
  • Preferred Pharmacies - 33% Co-insurance
  • Other Network Pharmacies - 33% Co-insurance
  • Preferred Pharmacies - 33% Co-insurance
  • Other Network Pharmacies - 33% Co-insurance
Initial Coverage Limits
  • Preferred Pharmacies - $4,660 Per Year
  • Other Network Pharmacies - $4,660 Per Year
  • Preferred Pharmacies - $4,660 Per Year
  • Other Network Pharmacies - $4,660 Per Year
What Medications are Covered View Covered Medications View Covered Medications

*30 day supply
Insulin Savings Program
As a member of the Covenant Advantage and Plus plans, you’ll have low, predictable copays on Select Insulins through our Insulin Savings Program.* Costs for Select Insulins will remain the same during the Initial Coverage and Coverage Gap phases of your prescription drug benefit. The program doesn’t apply during the Catastrophic Coverage stage. Note that this program isn’t available if you receive Extra Help from the government.
Preferred Retail Cost-Sharing
Tier 3 Select Insulins
  • 30-Day Supply: $35 copay
  • 60-Day Supply: $70 copay
  • 90-Day Supply: $105 copay
  • 30-Day Supply: $35 copay
  • 60-Day Supply: $70 copay
  • 90-Day Supply: $105 copay
Standard Retail Cost-Sharing
Tier 3 Select Insulins
  • 30-Day Supply: $35 copay
  • 60-Day Supply: $70 copay
  • 90-Day Supply: $105 copay
  • 30-Day Supply: $35 copay
  • 60-Day Supply: $70 copay
  • 90-Day Supply: $105 copay
Standard Mail-Order Cost-Sharing
Tier 3 Select Insulins
  • 30-Day Supply: $35 copay
  • 60-Day Supply: $70 copay
  • 90-Day Supply: $105 copay
  • 30-Day Supply: $35 copay
  • 60-Day Supply: $70 copay
  • 90-Day Supply: $105 copay
Out-of-Network Cost-Sharing
Tier 3 Select Insulins
  • 30-Day Supply: $35 copay
  • 30-Day Supply: $35 copay
*Select Insulins are those that are part of the Insulin Savings Program and therefore will incur low, consistent copays through the coverage gap. For information regarding which insulins are Select Insulins under the plan’s benefit, refer to the plan’s Prescription Drug Formulary. See the Evidence of Coverage for more information regarding Select Insulins, including full cost-sharing information.
Extra Benefits
Vision Care
By EyeMed®
  • $0 Copay for routine eye exam
  • Our plan pays up to $200 every calendar year for eyeglass frames, lenses and lens options, or contact lenses.
  • $0 Copay for routine eye exam
  • Our plan pays up to $400 every calendar year for eyeglass frames, lenses and lens options, or contact lenses.
Preventive Dental Care
By Delta Dental®		 Oral Exams - $0 Copay (two per calendar year)
  • Oral Exams - $0 Copay (two per calendar year)
  • $1,750 maximum benefit per year
    (combined preventive and comprehensive)
Comprehensive Dental Care
By Delta Dental®		 $30 Copay for Medicare-covered services**
  • $30 Copay for Medicare-covered services**
  • $100 Deductible
  • $1,750 maximum benefit per year
    (combined preventive and comprehensive)
Over-the-Counter (OTC) Items
  • $64 Per Quarter
  • Up to 2 orders per quarter; no rollovers
  • $89 Per Quarter
  • Up to 2 orders per quarter; no rollovers
Hearing
by TruHearing
  • $25 Copay for hearing exam
  • $1,000 allowance for up to 2 hearing aids every 2 years (both ears combined)
  • $25 Copay for hearing exam
  • $1,500 allowance for up to 2 hearing aids every 2 years (both ears combined)
Transportation Assistance $0 Copay for 20 one-way trips to approved locations per year $0 Copay for 30 one-way trips to approved locations per year
Fitness Membership SilverSneakers® included at no cost SilverSneakers® included at no cost
Travel Benefits Emergency or urgent care coverage if you are making a trip out of state or country Emergency or urgent care coverage if you are making a trip out of state or country
Post-Hospitalization Meal Benefit 28 meals, (2 meals/day for 14 days) delivered to the home after each discharge - (limited to 2 discharges annually) 28 meals, (2 meals/day for 14 days) delivered to the home after each discharge - (limited to 2 discharges annually)
Important Plan Documents to Download

Summary of Benefits (Updated: 10/01/2022)
Evidence of Coverage (Updated: 10/01/2022)
Drug Formulary (Updated: 10/01/2022)
Low Income Subsidy Information (Updated: 10/01/2022)
Star Ratings (Updated: 10/01/2022)
Calificaciones por Estrellas (Updated: 10/01/2022)
Provider Directory (Updated: 10/01/2022)
Annual Notice of Change (Updated: 10/01/2022)

Summary of Benefits (Updated: 10/01/2022)
Evidence of Coverage (Updated: 10/01/2022)
Drug Formulary (Updated: 10/01/2022)
Low Income Subsidy Information (Updated: 10/01/2022)
Star Ratings (Updated: 10/01/2022)
Calificaciones por Estrellas (Updated: 10/01/2022)
Provider Directory (Updated: 10/01/2022)
Annual Notice of Change (Updated: 10/01/2022)

2023 Covenant Advantage
(HMO-POS)		 2023 Covenant Advatange Plus
(HMO-POS)
Medical & Hospital
Monthly Premium
$0 $25
Maximum Out-of-Pocket Limit
$3,600 Per Year $3,600 Per Year
Annual Deductible
$0 $0
Preventive Care/Screenings
$0 Copay $0 Copay
Primary Care Physician Visits
$0 Copay $0 Copay
Specialist Doctor Visits
$30 Copay $30 Copay
No referrals for in-network specialist visits!*
Urgent Care
$60 Copay $60 Copay
Emergency Care
$90 Copay $90 Copay
Lab Services
$10 Copay $10 Copay
Home Healthcare
100% Coverage 100% Coverage
Chiropractic Care
$20 Copay $20 Copay
Inpatient Hospital Care
$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond 		$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
Outpatient Surgery at Hospital
$150 Copay $150 Copay
Outpatient Surgery at Ambulatory Surgery Center
$100 Copay $100 Copay
Part D Prescription Drug Coverage
Annual Deductible
  • Preferred Pharmacies - $0
  • Other Network Pharmacies - $0
  • Preferred Pharmacies - $0
  • Other Network Pharmacies - $0
Tier 1
Preferred Generic
  • Preferred Pharmacies - $0 Copay*
  • Other Network Pharmacies - $5 Copay*
  • Preferred Pharmacies - $0 Copay*
  • Other Network Pharmacies - $5 Copay*
Tier 2
Non-Preferred Generics
  • Preferred Pharmacies - $0 Copay*
  • Other Network Pharmacies - $10 Copay*
  • Preferred Pharmacies - $0 Copay*
  • Other Network Pharmacies - $10 Copay*
Tier 3
Preferred Brand Names
  • Preferred Pharmacies - $40 Copay*
  • Other Network Pharmacies - $45 Copay*
  • Preferred Pharmacies - $40 Copay*
  • Other Network Pharmacies - $45 Copay*
Tier 4
Non-Preferred Brand Names
  • Preferred Pharmacies - $90 Copay*
  • Other Network Pharmacies - $95 Copay*
  • Preferred Pharmacies - $90 Copay*
  • Other Network Pharmacies - $95 Copay*
Tier 5
Specialty Drugs
  • Preferred Pharmacies - 33% Co-insurance
  • Other Network Pharmacies - 33% Co-insurance
  • Preferred Pharmacies - 33% Co-insurance
  • Other Network Pharmacies - 33% Co-insurance
Initial Coverage Limits
  • Preferred Pharmacies - $4,660 Per Year
  • Other Network Pharmacies - $4,660 Per Year
  • Preferred Pharmacies - $4,660 Per Year
  • Other Network Pharmacies - $4,660 Per Year
What Medications are Covered
View Covered Medications View Covered Medications
*30 day supply
Insulin Savings Program
As a member of the Covenant Advantage and Plus plans, you’ll have low, predictable copays on Select Insulins through our Insulin Savings Program.* Costs for Select Insulins will remain the same during the Initial Coverage and Coverage Gap phases of your prescription drug benefit. The program doesn’t apply during the Catastrophic Coverage stage. Note that this program isn’t available if you receive Extra Help from the government.
Preferred Retail Cost-Sharing
Tier 3 Select Insulins
  • 30-Day Supply: $35 copay
  • 60-Day Supply: $70 copay
  • 90-Day Supply: $105 copay
Standard Retail Cost-Sharing
Tier 3 Select Insulins
  • 30-Day Supply: $35 copay
  • 60-Day Supply: $70 copay
  • 90-Day Supply: $105 copay
Standard Mail-Order Cost-Sharing
Tier 3 Select Insulins
  • 30-Day Supply: $35 copay
  • 60-Day Supply: $70 copay
  • 90-Day Supply: $105 copay
Out-of-Network Cost-Sharing
Tier 3 Select Insulins
  • 30-Day Supply: $35 copay
Extra Benefits
Vision Care
By EyeMed®
  • $0 Copay for routine eye exam
  • Our plan pays up to $200 every calendar year for eyeglass frames, lenses and lens options, or contact lenses.
  • $0 Copay for routine eye exam
  • Our plan pays up to $400 every calendar year for eyeglass frames, lenses and lens options, or contact lenses.
Preventive Dental Care
By Delta Dental®
  • Oral Exams - $0 Copay (two per calendar year)
  • $1,750 maximum benefit per year
    (combined preventive and comprehensive)
  • Oral Exams - $0 Copay (two per calendar year)
  • $1,750 maximum benefit per year
    (combined preventive and comprehensive)
Comprehensive Dental Care
By Delta Dental®
$30 Copay for Medicare-covered services**
  • $30 Copay for Medicare-covered services**
  • $100 Deductible
  • $1,250 maximum benefit per year
    (combined preventive and comprehensive)
Over-the-Counter (OTC) Items
  • $64 Per Quarter
  • Up to 2 orders per quarter; no rollovers
  • $89 Per Quarter
  • Up to 2 orders per quarter; no rollovers
Hearing
by TruHearing
  • $25 Copay for hearing exam
  • $1,000 allowance for up to 2 hearing aids every 2 years (both ears combined)
  • $25 Copay for hearing exam
  • $1,500 allowance for up to 2 hearing aids every 2 years (both ears combined)
Transportation Assistance
$0 Copay for 20 one-way trips to approved locations per year $0 Copay for 30 one-way trips to approved locations per year
Fitness Membership
SilverSneakers® included at no cost SilverSneakers® included at no cost
Travel Benefits
Emergency or urgent care coverage if you are making a trip out of state or country Emergency or urgent care coverage if you are making a trip out of state or country
Post-Hospitalization Meal Benefit
28 meals, (2 meals/day for 14 days) delivered to the home after each discharge - (limited to 2 discharges annually) 28 meals, (2 meals/day for 14 days) delivered to the home after each discharge - (limited to 2 discharges annually)
Important Plan Documents

Summary of Benefits (Updated: 10/01/2022)
Evidence of Coverage (Updated: 10/01/2022)
Drug Formulary (Updated: 10/01/2022)
Low Income Subsidy Information (Updated: 10/01/2022)
Star Ratings (Updated: 10/01/2022)
Calificaciones por Estrellas (Updated: 10/01/2022)
Provider Directory (Updated: 10/01/2022)
Annual Notice of Change (Updated: 10/01/2022)

Summary of Benefits (Updated: 10/01/2022)
Evidence of Coverage (Updated: 10/01/2022)
Drug Formulary (Updated: 10/01/2022)
Low Income Subsidy Information (Updated: 10/01/2022)
Star Ratings (Updated: 10/01/2022)
Calificaciones por Estrellas (Updated: 10/01/2022)
Provider Directory (Updated: 10/01/2022)
Annual Notice of Change (Updated: 10/01/2022)

*See Evidence of Coverage for more details

**Medicare-covere services are deemed to be medically necessary. These can include services and/or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms.

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