SummaCare Medicare Garnet (HMO)
Available to residents of Huron County, OH for 2026. Contract H3660, plan 053, segment 2.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Huron County
- Plan website
- Browse the SummaCare Medicare Garnet (HMO) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $35.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $35.00? |
| Monthly premium with full Extra Help (LIS) | $3.60? |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $4,800.00? |
| Drug deductible | $250.00Tier 1, 2 and 6 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO? |
| Contract / plan | H3660-053-2 |
| Offered by | SummaCare Medicare Advantage Plans |
| Parent organization | Summa Health |
| Formulary drugs | 3,744 |
| Formulary exception tier | 4? |
| Pharmacy search | openenrollment.medimpact.com/#/plancode?SUM032021PL |
| Member services | (888)464-8440TTY (800)750-0750 |
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)
- 4.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H3660 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $40 copay |
| Other health care professional | $20–$40 copay |
| Additional telehealth services | $0–$20 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | Not covered |
| 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–$50 copay(authorization required) |
| Lab services | $0–$5 copay(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $125 copay(authorization required) |
| Therapeutic radiology | 20% coinsurance(authorization required) |
| Outpatient x-rays | $0–$50 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $130 copay |
| Urgent care | $30 copay |
| Worldwide emergency coverage | $130 copay · $25,000 plan limit |
| Worldwide urgent care | $30 copay · $25,000 plan limit |
| Worldwide emergency transportation | $250 copay |
| Hospital care | |
| Inpatient hospital stay | $346 per day for days 1–6; $0 per day for days 7–90(authorization required) |
| Outpatient hospital services | $340 copay(authorization required) |
| Outpatient observation | $340 copay |
| Ambulatory surgical center | $290 copay(authorization required) |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $203 per day for days 21–100(authorization required) |
| Home health care | $0 copay |
| Kidney dialysis | 20% coinsurance(authorization required) |
| Rehabilitation | |
| Occupational therapy | $40 copay |
| Physical therapy and speech-language therapy | $40 copay |
| Cardiac rehabilitation | $0 copay |
| Pulmonary rehabilitation | $0 copay |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $346 per day for days 1–5; $0 per day for days 6–90(authorization required) |
| Outpatient mental health, individual session | $40 copay |
| Outpatient mental health, group session | $40 copay |
| Psychiatrist, individual session | $40 copay |
| Psychiatrist, group session | $40 copay |
| Partial hospitalization | $45 copay |
| Intensive outpatient program | $45 copay |
| Outpatient substance use, individual session | $40 copay |
| Outpatient substance use, group session | $40 copay |
| Opioid treatment program | $0 copay |
| Ambulance and transportation | |
| Ground ambulance | $250 copay(authorization required) |
| Air ambulance | $250 copay(authorization required) |
| Transportation to plan-approved locations | $0 copay(limits apply) |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 30% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | $0 copay |
| Diabetic therapeutic shoes or inserts | 20% coinsurance |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay |
| Routine chiropractic care | Not covered |
| Acupuncture | $20 copay(limits apply) |
| Foot exams and treatment (Medicare-covered) | $40 copay |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $0 copay |
| Preventive dental plan limit | $2,500 plan limit every year |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | Not covered |
| Endodontics (root canals) | $0 copay(limits apply) |
| Periodontics (gum disease) | $0 copay(limits apply) |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay |
| 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 | $235 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | $0 copay(limits apply) |
| Hearing? | |
| Hearing exam (Medicare-covered) | $0–$15 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aids (all types) | $395–$695 copay(limits apply) |
| 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 | $35 copay(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 | $60 allowance every three months |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay(referral required) |
| Health education | $0 copay(referral required) |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | $0 copay(referral required) |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay(referral required) |
| 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 | Not covered |
| 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 | $0 copay(referral required) |
| Adult day health services | Not covered |
| Home-based palliative care | $0 copay(referral required) |
| In-home support services | $0 copay(referral required) |
| 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 | 21% |
| Tier 4 | 40% |
| Tier 5 | 30% |
| Tier 6 | $0.00 |
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 | $6.00 | n/a | $0.00 | $15.00 | $0.00 |
| Tier 2: Generic | $0.00 | $10.00 | n/a | $0.00 | $25.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $6.00 | n/a | $0.00 | $15.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $6.00 | n/a | $0.00 | $15.00 | $0.00 |
| Tier 2: Generic | $0.00 | $10.00 | n/a | $0.00 | $25.00 | $0.00 |
| Tier 3: Preferred Brand | 21% | 25% | n/a | 21% | 25% | 21% |
| Tier 4: Non-Preferred Drug | 40% | 50% | n/a | 40% | 50% | 40% |
| Tier 5: Specialty Tier | 30% | 30% | 30% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $6.00 | n/a | $0.00 | $15.00 | $0.00 |
| 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 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 10 other OH counties
Benefits in plain text
SummaCare Medicare Garnet (HMO) (H3660-053-2) is a 2026 HMO Medicare Advantage plan offered by SummaCare Medicare Advantage Plans, available to residents of Huron County, OH.
The monthly premium is $35.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $3.60.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $4,800.00.
The drug deductible is $250.00. Tier 1, 2 and 6 exempt.
The plan's formulary lists 3,744 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: 21%; tier 4: 40%; tier 5: 30%; tier 6: $0.00.
CMS gives the plan's contract (H3660) 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.