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Memorial Hermann Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Memorial Hermann Advantage (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Memorial Hermann Advantage (HMO) in 2026, please refer to our full plan details page.
Memorial Hermann Advantage (HMO) is a HMO plan offered by Memorial Hermann Health System available for enrollment in 2025 to people living in TX -Houston area. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Memorial Hermann Advantage (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Memorial Hermann Advantage (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Memorial Hermann Advantage (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $200.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3400.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Memorial Hermann Advantage (HMO) prescription drug plan features an annual drug deductible of $200. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled at a standard pharmacy or through standard mail order. For Tier 2 generic drugs, standard copays are $5 for a one-month supply, $10 for a two-month supply, and $15 for a three-month supply. For higher-tier medications, the plan utilizes a coinsurance model for standard pharmacies and standard mail order. Tier 3 preferred brand drugs require a 23% coinsurance, and Tier 4 non-preferred drugs carry a 44% coinsurance. Specialty Tier 5 drugs are available with a 30% coinsurance for a one-month supply.
Additional Benefits
The Memorial Hermann Advantage (HMO) plan offers comprehensive healthcare coverage featuring no copay for primary care visits and no copay to a $25 copay for specialists. Inpatient hospital stays require a $400 copay per stay with no coinsurance, while emergency room visits carry a $150 copay that is waived if you are admitted within 48 hours. Most outpatient services and ground ambulance transports are covered under predictable, fixed copays with no coinsurance. This plan also provides robust supplemental benefits, including up to a $2,500 annual allowance for dental care and up to $500 yearly for eyewear with no copay. Routine eye and hearing exams are available for a $20 copay, and prescription hearing aids are covered with no copay up to a $500 annual limit. Additionally, members benefit from a $50 quarterly over-the-counter reimbursement allowance and up to 20 one-way transportation trips per year with no copay.
Inpatient Hospital See details
Memorial Hermann Advantage (HMO) covers inpatient acute and psychiatric hospital stays with a $400 copay per stay and no coinsurance, though prior authorization is required. The benefit is partially covered because room upgrades are not covered, but it does include unlimited additional days with no copay and coverage for non-Medicare-covered stays.
Outpatient Services See details
Memorial Hermann Advantage (HMO) covers outpatient services with no coinsurance, featuring a $150 copay for outpatient hospital services, a $200 copay per stay for observation services, and a $125 copay for ambulatory surgical center services. Outpatient substance abuse sessions have a $25 copay and no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Memorial Hermann Advantage (HMO) covers partial hospitalization services with a $50 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Memorial Hermann Advantage (HMO) covers ground ambulance services with a $250 copay (no coinsurance) and air ambulance services with a 20% coinsurance (no copay), both requiring prior authorization. Transportation services are partially covered, offering up to 20 one-way trips per year to plan-approved locations with no copay and no coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Memorial Hermann Advantage (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 48 hours, and urgently needed services with a $30 copay and no coinsurance. Worldwide emergency services are covered up to $50,000, featuring a $150 copay for emergency care, a $30 copay for urgent care, and a 20% coinsurance with no copay for emergency transportation.
Primary Care See details
Memorial Hermann Advantage (HMO) provides primary care physician services with no copay and no coinsurance, and specialist visits with a $0 to $25 copay and no coinsurance. Physical, occupational, and psychiatric therapies are covered with a $25 copay and no coinsurance, but podiatry is not covered, and some chiropractic and mental health specialty services are covered except for routine chiropractic care and individual or group mental health sessions.
Preventive Services See details
Memorial Hermann Advantage (HMO) covers preventive services with no copay and no coinsurance, including annual physicals, kidney disease education, and select benefits like fitness programs. However, additional preventive services are only partially covered, excluding health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation, telemonitoring, home safety modifications, and counseling.
Hearing Services See details
Hearing services are partially covered by Memorial Hermann Advantage (HMO), featuring routine hearing exams for a $20 copay and no coinsurance, and prescription hearing aids with no copay, no coinsurance, and a $500 annual limit. Over-the-counter hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
Vision services are partially covered by Memorial Hermann Advantage (HMO), featuring routine eye exams for a $20 copay and no coinsurance, while other eye exam services are not covered. Covered eyewear—including contact lenses, eyeglasses, frames, lenses, and upgrades—has no copay or coinsurance, with an annual combined maximum benefit of $500 and no deductible.
Dental Services See details
Memorial Hermann Advantage (HMO) provides partially covered dental services up to a $2,500 yearly maximum, though implant services, orthodontics, and maxillofacial prosthetics are not covered. Medicare-covered dental services require a $20 copay and no coinsurance, while other covered services range from no copay to a $1,129.70 copay and no coinsurance to 50% coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Memorial Hermann Advantage (HMO) with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Memorial Hermann Advantage (HMO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Memorial Hermann Advantage (HMO) covers medical equipment with no copays, though a 20% coinsurance applies to durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes. Diabetic supplies feature coinsurance ranging from no coinsurance up to 20% from specified manufacturers, and prior authorization is required for some items.
Diagnostic and Radiological Services See details
Memorial Hermann Advantage (HMO) offers partially covered diagnostic and radiological services with no coinsurance, though lab services and outpatient X-ray services are not covered. Covered diagnostic procedures and therapeutic radiological services require a $25 copay, while diagnostic radiological services have no copay.
Home Health Services See details
Memorial Hermann Advantage (HMO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by Memorial Hermann Advantage (HMO) with no coinsurance, but in practice only some services are covered because cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require a $25 copay.
Skilled Nursing Facility (SNF) See details
Memorial Hermann Advantage (HMO) covers skilled nursing facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20 and a $125 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Memorial Hermann Advantage (HMO) partially covers other services, offering a $50 quarterly over-the-counter (OTC) reimbursement allowance and limited-duration meals for chronic illnesses with no copay and no coinsurance. Acupuncture and other miscellaneous services are not covered under this benefit.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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