Select Founders, LLC
Plan ID: H1587-3-0
Plan Summary Page2026 Tribute Select (HMO-POS I-SNP) H1587 — 003 — 0 is a Medicare Advantage plan with drug coverage.
Learn more about Tribute Select (HMO-POS I-SNP) H1587 - 003 - 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.
$8.90 /mo
Monthly premium
$615.00
Drug deductible
$9250.00
Out-of-pocket maximum (Out-of-Network)
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The Tribute Select (HMO-POS I-SNP) plan offers coverage for essential medical services with a consistent cost structure, generally requiring a twenty percent coinsurance and no copay. This cost-sharing applies to primary care, outpatient services, emergency care, diagnostic tests, and durable medical equipment. Additionally, members benefit from having no copay and no coinsurance for home health services, annual physicals, and Medicare-covered preventive care. However, the plan does not cover several routine services, including routine dental, hearing, vision, and cardiac rehabilitation. Prior authorization is required for key benefits like inpatient hospital stays, skilled nursing facility care, and home health services. For prescription home infusion drugs, members can expect no copay and up to twenty percent coinsurance, except for Part B insulin which carries a thirty-five dollar copay.
The Tribute Select (HMO-POS I-SNP) Medicare plan features a defined standard drug benefit with an annual prescription drug deductible of $615.00. After meeting this deductible, you will pay copays or coinsurance during the initial coverage phase until your total drug costs reach $2,100.00. Additionally, individuals who qualify for the Low-Income Subsidy can receive a reduced Part D premium of $8.90. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and will have no copay for Medicare Part D covered drugs. While there is no cost for standard covered prescriptions in this phase, you may still pay a share of the costs for any excluded drugs. This coverage structure helps protect you from high prescription drug expenses throughout the year.
Plan data sourced from the official CMS 2026 public benefit files. Reviewed by Walt Whitney. How we source and review plan information.
2026 Tribute Select (HMO-POS I-SNP) H1587 — 003 — 0 is a HMO-POS I-SNP offered in Arkansas by Select Founders, LLC. It has a monthly premium of $8.90 and includes a Part B premium discount of $57.70.
Important:
2026 Tribute Select (HMO-POS I-SNP) H1587 — 003 — 0 is a Institutional Special Needs Type plan. You can only enroll in this plan if you meet specific criteria.
Monthly plan premium
$8.90
Standard Part B premium
$202.90
Part B premium reduction
$57.70
Estimated net Part B premium after giveback
$145.20
Note:
The standard Medicare Part B premium for 2026 is $202.90. Your actual Part B premium may differ based on income (IRMAA), late enrollment penalties, Medicaid assistance, disability status, or other factors. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
Yes
Out-of-pocket maximum (In-Network)
N/A
Out-of-pocket maximum (Out-of-Network)
$9250.00
Out-of-pocket maximum (Combined)
N/A
Conditions Covered
None
Plan Organization:
Select Founders, LLC
Plan Type:
HMO-POS I-SNP
Location:
Arkansas
Drugs Covered:
Yes
Drug Formulary:
Pharmacies:
Doctors Link:
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Drug deductible
$615
Note:
This plan does not charge an annual deductible for all drugs. The $615.00 annual deductible only applies to drugs in certain tiers.
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Tribute Select (HMO-POS I-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
$615.00
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 |
|---|---|
$8.90 | $8.90 |
After you pay your $615.00 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 $2100.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
|---|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2100.00, 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.
Tribute Select (HMO-POS I-SNP) also provides the following benefits.
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Do you charge the Medicare-defined cost share for tier 1?
Yes
Periodicity
Original Medicare
Not covered.
Not covered.
Not covered.
Inpatient Hospital Psychiatric benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Do you charge the Medicare-defined cost share for tier 1?
Yes
Periodicity
Original Medicare
Not covered.
Not covered.
Outpatient Services benefits are covered.
All Outpatient Hospital Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Coinsurance
Medicare-covered Outpatient Hospital Services, Medicare-covered Observation Services
Outpatient Hospital Services benefits are covered.
Cost Sharing:
Observation Services benefits are covered.
Cost Sharing:
Ambulatory Surgical Center (ASC) Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Outpatient Substance Abuse Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Outpatient Substance Abuse services have a Coinsurance
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Group Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Outpatient Blood Services benefits are covered.
Cost Sharing:
More Details:
Is there a deductible?
No
Do you waive the deductible for the first three pints of blood?
No
Partial Hospitalization benefits are covered.
Partial Hospitalization benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Coinsurance percent
20
Partial Hospitalization benefits are covered.
Cost Sharing:
More Details:
Coinsurance percent
20
Ambulance and Transportation Services benefits are covered.
All Ambulance Services benefits are covered.
More Details:
Is there a coinsurance?
Yes
Which Services have a Coinsurance
Medicare-covered Ground Ambulance Services, Medicare-covered Air Ambulance Services
Is this Coinsurance waived if admitted to hospital?
No
Is there a copayment ?
No
Ground Ambulance Services benefits are covered.
Cost Sharing:
Air Ambulance Services benefits are covered.
Cost Sharing:
Transportation Services benefits are covered.
Not covered.
Not covered.
Emergency Services benefits are covered.
Emergency Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
Yes
Is the coinsurance for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Days
Enter number of days or hours
3
Is there a copayment?
No
Maximum per visit amount
115.00
Does the cost sharing count towards any plan-level deductible?
No
Urgently Needed Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
Yes
Is the coinsurance for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Days
Enter number of days or hours
3
Is there a copayment?
No
Maximum per visit amount
40.00
Does the cost sharing count towards any plan-level deductible?
No
Worldwide Emergency Services benefits are covered.
Not covered.
Not covered.
Not covered.
Primary Care benefits are covered.
Primary Care Physician Services benefits are covered.
Cost Sharing:
Chiropractic Services benefits are covered.
Cost Sharing:
More Details:
Which Chiropractic Services have a Coinsurance
Routine Care
Not covered.
Occupational Therapy Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Physician Specialist Services benefits are covered.
Cost Sharing:
Mental Health Specialty Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Mental Health Specialty Services have a Coinsurance
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Group Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Not covered.
Other Health Care Professional benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Psychiatric Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Psychiatric Services have a Coinsurance
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Group Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Physical Therapy and Speech-Language Pathology Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Additional Telehealth Benefits benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Medicare-covered benefits that may have Additional Telehealth Benefits available
1a: Inpatient Hospital-Acute, 1b: Inpatient Hospital Psychiatric, 2: Skilled Nursing Facility (SNF), 3-1: Cardiac Rehabilitation Services, 3-2: Intensive Cardiac Rehabilitation Services, 3-3: Pulmonary Rehabilitation Services, 3-4: SET for PAD Services, 4a: Emergency Services, 4b: Urgently Needed Services, 5a: Partial Hospitalization Program, 5b: Intensive Outpatient Program Services, 6: Home Health Services, 7a: Primary Care Physician Services, 7b: Chiropractic Services, 7c: Occupational Therapy Services, 7d: Physician Specialist Services, 7e1: Individual Sessions for Mental Health Specialty Services, 7e2: Group Sessions for Mental Health Specialty Services, 7f: Podiatry Services, 7g: Other Health Care Professional, 7h1: Individual Sessions for Psychiatric Services, 7h2: Group Sessions for Psychiatric Services, 7i: Physical Therapy and Speech-Language Pathology Services, 7k: Opioid Treatment Program Services, 8a1: Diagnostic Procedures/Tests, 8a2: Lab Services, 8b1: Diagnostic Radiological Services, 8b2: Therapeutic Radiological Services, 8b3: Outpatient X-Ray Services, 9a1: Outpatient Hospital Services, 9a2: Observation Services, 9b: Ambulatory Surgical Center (ASC) Services, 9c1: Individual Sessions for Outpatient Substance Abuse, 9c2: Group Sessions for Outpatient Substance Abuse, 9d: Outpatient Blood Services, 10a1: Ground Ambulance Services, 10a2: Air Ambulance Services, 11a: Durable Medical Equipment (DME), 11b1: Prosthetic Devices, 11b2: Medical Supplies, 11c1: Diabetic Supplies, 11c2: Diabetic Therapeutic Shoes/Inserts, 12: Dialysis Services, 14a: Medicare-covered Zero Dollar Preventive Services, 14d: Kidney Disease Education Services, 14e1: Glaucoma Screening, 14e2: Diabetes Self-Management Training, 14e4: Digital Rectal Exams, 14e5: EKG following Welcome Visit, 15-1-I: Medicare Part B Insulin Drugs, 15-2: Medicare Part B Chemotherapy/Radiation Drugs, 15-3: Other Medicare Part B Drugs, 16a: Medicare Dental Services, 17a: Eye Exams, 17b: Eyewear, 18a: Hearing Exams
Opioid Treatment Program Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Preventive Services benefits are covered.
Medicare-covered Zero Dollar Preventive Services benefits are covered.
Annual Physical Exam benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a maximum plan benefit coverage amount?
No
Additional Preventive Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a service-specific Maximum Plan Benefit Coverage amount for Other Defined Supplemental Benefits?
No
Health Education benefits are covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Kidney Disease Education Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Other Preventive Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Coinsurance
Medicare-covered Glaucoma Screening, Medicare-covered Diabetes Self-Management Training, Medicare-covered Digital Rectal Exams, Medicare-covered EKG following Welcome Visit
Is a referral required for any Services?
No
Glaucoma Screening benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Diabetes Self-Management Training benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Digital Rectal Exams benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
EKG following Welcome Visit benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Hearing Services benefits are covered.
Hearing Exams benefits are covered.
Cost Sharing:
More Details:
Which Hearing Exam Benefits have a Coinsurance
Routine Hearing Exams
Minimum coinsurance
20
Is there a deductible?
No
Not covered.
Not covered.
Prescription Hearing Aids benefits are covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Vision Services benefits are covered.
Eye Exams benefits are covered.
Cost Sharing:
More Details:
Which Eye Exams have a Coinsurance
Routine Eye Exams
Is there a deductible?
No
Not covered.
Eyewear benefits are covered.
Cost Sharing:
More Details:
Which Eyewear Benefits have a Coinsurance
Contact lenses
Is there a deductible?
No
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Dental Services benefits are covered.
Medicare Dental Services benefits are covered.
Cost Sharing:
More Details:
Coinsurance percentage
20
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Home Infusion bundled Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Medicare Part B Rx Drugs have a Coinsurance
Medicare Part B Chemotherapy/Radiation Drugs, Other Medicare Part B Drugs
Does this plan have a service specific maximum enrollee out-of-pocket cost (MOOP)?
No
Does the plan offer step therapy?
No
Does the plan provide Part D home infusion drugs as part of a bundled service as a mandatory supplemental benefit?
No
Insulin benefits are covered.
Medicare Part B Insulin Drugs benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Does the Part B drugs - Insulin cost sharing count towards any plan-level deductible?
No
Medicare Part B Chemotherapy/Radiation Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Other Medicare Part B Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Dialysis Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Equipment benefits are covered.
Durable Medical Equipment (DME) benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?
No
Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Prosthetics/Medical Supplies have a Coinsurance
Medicare-covered Prosthetic Devices, Medicare-covered Medical Supplies
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Supplies benefits are covered.
Cost Sharing:
Diabetic Equipment benefits are covered.
Cost Sharing:
More Details:
Which Diabetic Supplies and Services have a Coinsurance
Medicare-covered Diabetic Supplies, Medicare-covered Diabetic Therapeutic Shoes or Inserts
Do you limit Diabetic supplies and services to those from specified manufacturers
No
Diabetic Supplies benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Diabetic Therapeutic Shoes/Inserts benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services benefits are covered.
Cost Sharing:
More Details:
Which Outpatient Diagnostic Procedures/Tests/Lab Services have a Coinsurance
Medicare-covered Diagnostic Procedures/Tests, Medicare-covered Lab Services
Is there a copayment?
No
Diagnostic Procedures/Tests benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Lab Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
All Radiological Services benefits are covered. Prior Authorization is required.
More Details:
Is there a copayment?
No
Not covered.
Not covered.
Not covered.
Home Health Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Cardiac Rehabilitation Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Cardiac and Pulmonary Rehabilitation Services have a Coinsurance
Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, Additional Cardiac Rehabilitation Services
Not covered.
Not covered.
Not covered.
Not covered.
Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
Yes
Do you allow less than 3 day inpatient hospital stay prior to SNF admission?
Yes
Days
Zero
Do you charge the Medicare-defined cost share for tier 1?
Yes
Periodicity
Original Medicare
Not covered.
Other Services benefits are covered.
Not covered.
Not covered.
Not covered.
Other 1 benefits are covered. A doctor referral is required.
Cost Sharing:
More Details:
Service Name
Advanced Placement of DME
Is there a maximum plan benefit coverage?
No
Not covered.
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