A non-government entity
Intermountain Health Care, Inc.
Plan ID: H1994-40-0
Select Health Medicare Dual (HMO D-SNP)
2025 Select Health Medicare Dual (HMO D-SNP) H1994 — 040 — 0 is a Medicare Advantage plan with drug coverage. It has received a 4-out-of-5 star rating from CMS for 2025.
Learn more about Select Health Medicare Dual (HMO D-SNP) H1994 - 040 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.
4 / 5 stars for 2025
$21.30 /mo
Monthly premium
$590.00
Drug deductible
$9350.00
Out-of-pocket maximum
Enroll online
Call to enroll
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Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!
Plan Overview
2025 Select Health Medicare Dual (HMO D-SNP) H1994 — 040 — 0 is a HMO D-SNP offered in by Intermountain Health Care, Inc.. It has a monthly premium of $21.30.
Important:
2025 Select Health Medicare Dual (HMO D-SNP) H1994 — 040 — 0 is a Dual-Eligible Special Needs Type plan. You can only enroll in this plan if you meet specific criteria.
Premium Breakdown
Standard Part B Premium
$185.00
Part B premium reduction
- $0
Monthly Plan Premium
$21.30
Total Premium:
$206.30
Note:
The standard Medicare Part B premium for 2025 is $185.00. Your premium may differ based on factors like late enrollment, income (IRMAA), or disability status. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
Yes
Out-of-pocket maximum
$9350.00
Conditions Covered
None
Plan Organization:
Intermountain Health Care, Inc.
Plan Type:
HMO D-SNP
Location:
Drugs Covered:
Yes
Drug Formulary:
Not yet released
Pharmacies:
Not yet released
Doctor Choice:
Doctors Link:
Not yet released
Deductibles
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Drug deductible
$590
Note:
This plan does not charge an annual deductible for all drugs. The $590.00 annual deductible only applies to drugs in certain tiers.
Sign up for Select Health Medicare Dual (HMO D-SNP)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
Select Health Medicare Dual (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Benefit Type
Defined Standard
Prescription drug deductible
$590.00
Part D Premium Reduction
This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.
Part D | LIS Full |
|---|---|
$21.30 | $21.30 |
Initial Coverage Phase
After you pay your $590.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2000.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
|---|---|---|---|---|
1. Preferred Generic | - | - | - | - |
2. Standard Generic | - | - | - | - |
3. Preferred Brand | - | - | - | - |
4. Non-Preferred Drug | - | - | - | - |
5. Specialty Tier | - | - | - | - |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
Select Health Medicare Dual (HMO D-SNP) also provides the following benefits.
Note:
Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.
Comprehensive dental
Preventive dental
Diagnostic procedures/lab services/imaging
Doctor visits
Emergency care/Urgent care
Foot care (podiatry services)
Ground ambulance
Hearing
Inpatient hospital coverage
Outpatient hospital coverage
Optional benefits
Medical equipment/supplies
Medicare Part B drugs
Mental health services
Preventive care
Rehabilitation services
Skilled Nursing Facility
Transportation
Vision
Wellness programs (eg, fitness, nursing hotline)
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
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Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
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