Select Health Medicare + Kroger (HMO)
Available to residents of Nye County, NV for 2026. Contract H1994, plan 021, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
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- Plan website
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Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $1,500.00? |
| Drug deductible | $200.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO? |
| Contract / plan | H1994-021-0 |
| Offered by | Select Health |
| Parent organization | Intermountain Health Care, Inc. |
| Formulary drugs | 3,859 |
| Formulary exception tier | 4? |
| Pharmacy search | www.selecthealth.org/medicare |
| Member services | (855)442-9940TTY (800)346-4128 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 4 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 3 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H1994 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $0 copay(authorization and referral required) |
| Other health care professional | $0 copay(referral required) |
| Additional telehealth services | $0 copay(referral required) |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 0%–20% coinsurance(authorization and referral required) |
| Lab services | $0 copay(authorization and referral required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$75 copay(authorization and referral required) |
| Therapeutic radiology | 20% coinsurance(authorization and referral required) |
| Outpatient x-rays | $0 copay(authorization and referral required) |
| Emergency and urgent care | |
| Emergency room | $150 copay |
| Urgent care | $20 copay |
| Worldwide emergency coverage | $150 copay |
| Worldwide urgent care | $20 copay |
| Worldwide emergency transportation | $275 copay |
| Hospital care | |
| Inpatient hospital stay | $50 per day for days 1–4; $0 per day for days 5–90(authorization and referral required) |
| Outpatient hospital services | $0 copay(authorization and referral required) |
| Outpatient observation | $0 copay(referral required) |
| Ambulatory surgical center | $0 copay(authorization and referral required) |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $20 per day for days 1–20; $218 per day for days 21–40; $0 per day for days 41–100(authorization and referral required) |
| Home health care | $0 copay(authorization and referral required) |
| Kidney dialysis | 20% coinsurance(referral required) |
| Rehabilitation | |
| Occupational therapy | $0 copay(authorization and referral required) |
| Physical therapy and speech-language therapy | $0 copay(authorization and referral required) |
| Cardiac rehabilitation | $0 copay(authorization and referral required) |
| Pulmonary rehabilitation | $0 copay(authorization and referral required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $120 per day for days 1–10; $0 per day for days 11–90(authorization and referral required) |
| Outpatient mental health, individual session | $15 copay(referral required) |
| Outpatient mental health, group session | $10 copay(referral required) |
| Psychiatrist, individual session | $15 copay(referral required) |
| Psychiatrist, group session | $10 copay(referral required) |
| Partial hospitalization | $55 copay(authorization and referral required) |
| Intensive outpatient program | $55 copay(authorization required) |
| Outpatient substance use, individual session | $25 copay(authorization and referral required) |
| Outpatient substance use, group session | $10 copay(authorization and referral required) |
| Opioid treatment program | $30 copay(authorization and referral required) |
| Ambulance and transportation | |
| Ground ambulance | $275 copay(authorization required) |
| Air ambulance | $275 copay(authorization required) |
| Transportation to plan-approved locations | $0 copay(authorization and referral required, limits apply) |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $10 copay(authorization and referral required) |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $0 copay(referral required) |
| Routine foot care | $0 copay(referral required, limits apply) |
| Dental? | |
| Medicare-covered dental services | $0 copay(authorization required) |
| Preventive dental plan limit | $1,250 plan limit every year |
| Oral exams | $0 copay(authorization required, limits apply) |
| Cleanings | $0 copay(authorization required, limits apply) |
| Fluoride treatment | $0 copay(authorization required, limits apply) |
| Dental x-rays | $0 copay(authorization required, limits apply) |
| Other diagnostic dental services | $0 copay(authorization required, limits apply) |
| Other preventive dental services | $0 copay(authorization required, limits apply) |
| Endodontics (root canals) | 50% coinsurance |
| Periodontics (gum disease) | 50% coinsurance |
| Dentures and other removable prosthodontics | 50% coinsurance |
| Maxillofacial prosthetics | 50% coinsurance |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | 50% coinsurance |
| Oral and maxillofacial surgery | 50% coinsurance |
| Orthodontics | Not covered |
| Adjunctive general services | 50% coinsurance |
| Vision? | |
| Eye exam (Medicare-covered) | $0 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $200 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | Not covered |
| Eyeglass frames | Not covered |
| Eyewear upgrades | $0 copay(limits apply) |
| Hearing? | |
| Hearing exam (Medicare-covered) | $0 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay(limits apply) |
| Hearing aids (all types) | $699–$999 copay |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | Not covered |
| Meals after a hospital stay or for a chronic condition | $0 copay(authorization required) |
| Fitness benefit | $0 copay |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | $0 copay |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | $0 copay |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $0.00 |
| Tier 3 | $40.00 |
| Tier 4 | $90.00 |
| Tier 5 | 30% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $15.00 | $0.00 | $0.00 | $45.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $15.00 | $0.00 | $0.00 | $45.00 | $0.00 |
| Tier 3: Preferred Brand | $40.00 | $47.00 | $40.00 | $120.00 | $141.00 | $120.00 |
| Tier 4: Non-Preferred Drug | $90.00 | $100.00 | $90.00 | $270.00 | $300.00 | $270.00 |
| Tier 5: Specialty Tier | 30% | 30% | 30% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 1 other NV county
Benefits in plain text
Select Health Medicare + Kroger (HMO) (H1994-021-0) is a 2026 HMO Medicare Advantage plan offered by Select Health, available to residents of Nye County, NV.
The monthly premium is $0.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $1,500.00.
The drug deductible is $200.00. Tier 1 and 2 exempt.
The plan's formulary lists 3,859 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $0.00; tier 3: $40.00; tier 4: $90.00; tier 5: 30%.
CMS gives the plan's contract (H1994) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.