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| Medicare Advantage Plan | Effective 01.01.22 |
| Monthly Plan Premium | $314.94 per member per month1 You must continue to pay your Medicare Part B premium |
| Deductible | $0 – There is no yearly deductible for medical services |
| Out-of-Pocket Responsibility | Your yearly limit(s) for this plan – $1,500 |
| Covered Benefits | What You Pay |
| Inpatient Hospital Coverage2,3 | $0 copay |
| Doctor’s office visits: Primary care physician and Specialist2,3 | $0 copay |
| Preventive care | $0 copay |
| Urgently needed services | $0 copay |
| Lab services and X-ray | $0 copay |
| Value-Added Services | What You Pay |
| Routine chiropractic and acupuncture | $15 copay; up to 20 combined visits annually |
| Over-the-counter credits | $100 per quarter |
| Fitness program | $0 copay |
| Eyewear allowance | up to $200 every two years |
| 1Individual subscriber premium only 2Services may require prior authorization 3Services may require a referral from your doctor |
If you need help finding a doctor or have questions about covered services, call Western Health Advantage at 888.WHA.PERS (888.942.7377 toll-free; 711 TTY. Available seven days a week, 7 a.m. to 8 p.m. Translation services and assistance are available. Hard copies of WHA MyCare Select (HM0) plan documents are available by filling out the online request form or calling WHA at the number above.
