AHM_Basic (HMO) 2012
The AHM_Basic (HMO) is a plan without prescription drug coverage that is designed for Medicare beneficiaries who has Part D Prescription Medicines coverage. These might include private sector retirees or veterans.
$0 monthly premium
$0 deductible
$0 copayment on hospitalizations
$0 copayment on PCP visits and visits to participating specialists
$0 copayment on laboratories and X-rays
$0 copayment on Oral Nutritional Supplements *
$0 copayment on Adult Diapers (incontinence) *
$0 copayment on Shower Chairs *
Up to $750 annually on Comprehensive Dental Services
* Certain restrictions apply.
Plan is available to beneficiaries residing in one of the 78 municipalities of Puerto Rico.
Please refer to the Evidence of Coverage and/or the Summary of Benefits for information on copayments/coinsurance.
Annual Notice of Change AHM_Basic (HMO) H5774_1027 _12_05_E File & Use 09172011
Evidence of Coverage AHM_Basic (HMO) H5774_1027 _12_05_E File & Use 09172011
Summary of Benefits AHM_Basic (HMO) H5774_1001_12_06_E CMS Approved 09292011
Last Updated 10/06/2011
