Sparrow Advantage Plans in Your Area

Sparrow Advantage (HMO-POS) Sparrow Advantage Plus (HMO-POS)
Monthly Premium $0 $25
Maximum Out-of-Pocket Limit $3,800 Per Year $3,800 Per Year
Annual Deductible$0 $0
Preventive Care/Screenings $0 Copay $0 Copay
Primary Care Physician Visits $5 Copay $5 Copay
Specialist Doctor Visits $30 Copay $30 Copay
Urgent Care $60 Copay $60 Copay
Emergency Care $90 Copay $90 Copay
Lab Services $10 Copay $10 Copay
Home Health Care 100% Coverage 100% Coverage
Chiropractic Care $20 Copay $20 Copay
Inpatient Hospital Care $200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
Outpatient Surgery at Hospital $150 Copay $150 Copay
Outpatient Surgery at Ambulatory Surgery Center $100 Copay $100 Copay
Preferred Pharmacies Other Network Pharmacies Preferred Pharmacies Other Network Pharmacies
Annual Deductible$0$0 $0 $0
Tier 1 – Preferred Generic$0 Copay$5 Copay $0 Copay $5 Copay
Tier 2 – Generics$0 Copay $10 Copay $0 Copay $10 Copay
Tier 3 – Preferred Brands$40 Copay $45 Copay $40 Copay $45 Copay
Tier 4 – Non-Preferred Brands$90 Copay $95 Copay $90 Copay $95 Copay
Tier 5 – Specialty Drugs33% Co-insurance33% Co-insurance 33% Co-insurance 33% Co-insurance
Initial Coverage Limits$4,020 Per Year $4,020 Per Year $4,020 Per Year $4,020 Per Year
What Medications are Covered? Download our Prescription Drug Formulary to find out which medications are covered as part of your Sparrow Advantage plan of choice
View Covered Medications View Covered Medications
Vision Care$25 Copay for routine eye exam
$0 Copay for a pair of eyeglass frames or contact lenses (2 six packs)
$25 Copay for routine eye exam
$0 Copay for a pair of eyeglass frames or contact lenses (2 six packs)
Preventive Dental Care$0 Copay $0 Copay
Comprehensive Dental CareNot Covered $100 Deductible
$1,000 maximum benefit per year
Over-the-Counter (OTC) Items$55 Per Quarter,
up to 2 orders per quarter; no rollover
$80 Per Quarter,
up to 2 orders per quarter; no rollover
Hearing$25 Copay for hearing exam
$1,000 allowance for up to 2 hearing aids
every 2 calendar years (both ears combined)
$25 Copay for hearing exam
$1,500 allowance for up to 2 hearing aids
every 2 calendar years (both ears combined)
Transportation Assistance$0 Copay for 20 one-way trips
to approved locations per year
$0 Copay for 30 one-way trips
to approved locations per year
SilverSneakersIncluded at no additional cost Included at no additional cost
Travel BenefitsEmergency or urgent care coverage if you are making a trip out of state or country Emergency or urgent care coverage if you are making a trip out of state or country

Sparrow Advantage (HMO-POS)

Hospital & Medical Coverage

Monthly Premium $25
Maximum Out-of-Pocket Limit $3,800 Per Year
Annual Deductible $0
Preventive Care/Screenings $0 Copay
Primary Care Physician Visits $5 Copay
Specialist Doctor Visits $30 Copay
Urgent Care $60 Copay
Emergency Care $90 Copay
Lab Services $10 Copay
Home Health Care 100% Coverage
Chiropractic Care $20 Copay
Inpatient Hospital Care $200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
Outpatient Surgery at Hospital $150 Copay
Outpatient Surgery at Ambulatory Surgery Center $100 Copay

Part D Drug Coverage

Preferred Pharmacies Other Network Pharmacies
Annual Deductible$0$0
Tier 1 – Preferred Generic$0 Copay$5 Copay
Tier 2 – Generics$0 Copay $10 Copay
Tier 3 – Preferred Brands$40 Copay $45 Copay
Tier 4 – Non-Preferred Brands$90 Copay $95 Copay
Tier 5 – Specialty Drugs33% Co-insurance33% Co-insurance
Initial Coverage Limits$4,020 Per Year $4,020 Per Year

Extra Benefits

Vision Care $25 Copay for routine eye exam
$0 Copay for a pair of eyeglass frames or contact lenses (2 six packs)
Preventive Dental Care $0 Copay
Comprehensive Dental Care $100 Deductible; $1,000 maximum benefit per year
Over-the-Counter (OTC) Items $55 Per Quarter, up to 2 orders per quarter; no rollover
Hearing $25 Copay for hearing exam
$1,000 allowance for up to 2 hearing aids every 2 calendar years (both ears combined)
Transportation Assistance$0 Copay for 30 one-way trips to approved locations per year
SilverSneakers Included at no additional cost
Travel Benefits Emergency or urgent care coverage if you are making a trip out of state or country

Sparrow Advantage Plus (HMO-POS)

Medical & Hospital Coverage

Monthly Premium $25
Maximum Out-of-Pocket Limit $3,800 Per Year
Annual Deductible $0
Preventive Care/Screenings $0 Copay
Primary Care Physician Visits $5 Copay
Specialist Doctor Visits $30 Copay
Urgent Care $60 Copay
Emergency Care $90 Copay
Lab Services $10 Copay
Home Health Care 100% Coverage
Chiropractic Care $20 Copay
Inpatient Hospital Care $200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
Outpatient Surgery at Hospital $150 Copay
Outpatient Surgery at Ambulatory Surgery Center $100 Copay

Part D Drug Coverage

Preferred Pharmacies Other Network Pharmacies
Annual Deductible $0 $0
Tier 1 – Preferred Generic $0 Copay $5 Copay
Tier 2 – Generics$0 Copay $10 Copay
Tier 3 – Preferred Brands$40 Copay $45 Copay
Tier 4 – Non-Preferred Brands$90 Copay $95 Copay
Tier 5 – Specialty Drugs 33% Co-insurance 33% Co-insurance
Initial Coverage Limits $4,020 Per Year $4,020 Per Year

Extra Benefits

Vision Care$25 Copay for routine eye exam
$0 Copay for a pair of eyeglass frames or contact lenses (2 six packs)
Preventive Dental Care$0 Copay
Comprehensive Dental Care$100 Deductible; $1,000 maximum benefit per year
Over-the-Counter (OTC) Items$80 Per Quarter, up to 2 orders per quarter; no rollover
Hearing $25 Copay for hearing exam
$1,500 allowance for up to 2 hearing aids every 2 calendar years (both ears combined)
Transportation Assistance$0 Copay for 30 one-way trips to approved locations per year
SilverSneakersIncluded at no additional cost
Travel BenefitsEmergency or urgent care coverage if you are making a trip out of state or country

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