St. Luke's Advantage Rx 01 (HMO)
Available to residents of Ada County, ID for 2027. Contract H3012, plan 001, segment 0.
- ✉ 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 Ada County
- Plan website
- Browse the St. Luke's Advantage Rx 01 (HMO) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
New for 2027. This plan has no 2026 predecessor in the CMS crosswalk. Every ID plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $77.00 |
|---|---|
| — medical (Part C) part | $17.00 |
| — drug (Part D) part | $60.00? |
| Monthly premium with full Extra Help (LIS) | $31.50?drug (Part D) part $14.50; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | $250.00 |
| In-network out-of-pocket maximum | $5,950.00? |
| Drug deductible | $299.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | HMO? |
| Contract / plan | H3012-001-0 |
| Offered by | St. Luke's Health Plan |
| Parent organization | St. Luke's Health System, Inc. |
| Formulary tiers | 5 |
| Formulary exception tier | 4? |
| Pharmacy search | www.stlukeshealthplan.org/members/resources/pharmacy |
| Member services | (833)840-1216TTY 711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H3012 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $0–$30 copay |
| Other health care professional | $0–$30 copay |
| Additional telehealth services | $0–$30 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | 20% coinsurance |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 0%–20% coinsurance(authorization required) |
| Lab services | 0%–20% coinsurance(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$300 copay |
| Therapeutic radiology | 20% coinsurance |
| Outpatient x-rays | $0–$15 copay |
| Emergency and urgent care | |
| Emergency room | $130 copay |
| Urgent care | $30 copay |
| Worldwide emergency coverage | $130 copay |
| Worldwide urgent care | $30 copay |
| Worldwide emergency transportation | Not covered |
| Hospital care | |
| Inpatient hospital stay | $400 per day for days 1–5; $0 per day for days 6–90(authorization required) |
| Outpatient hospital services | $0–$400 copay |
| Outpatient observation | $400 copay |
| Ambulatory surgical center | $0–$400 copay |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $221 per day for days 21–100(authorization required) |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance(authorization required) |
| Rehabilitation | |
| Occupational therapy | $20 copay(authorization required) |
| Physical therapy and speech-language therapy | $20 copay(authorization required) |
| Cardiac rehabilitation | $0 copay |
| Pulmonary rehabilitation | $0 copay |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $400 per day for days 1–5; $0 per day for days 6–90(authorization required) |
| Outpatient mental health, individual session | $0 copay |
| Outpatient mental health, group session | $0 copay |
| Psychiatrist, individual session | $0 copay |
| Psychiatrist, group session | $0 copay |
| Partial hospitalization | $75 copay |
| Intensive outpatient program | $75 copay |
| Outpatient substance use, individual session | $0 copay |
| Outpatient substance use, group session | $0 copay |
| Opioid treatment program | $0 copay |
| Ambulance and transportation | |
| Ground ambulance | $295 copay(authorization required) |
| Air ambulance | $295 copay(authorization required) |
| Transportation to plan-approved locations | Not covered |
| 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) | $15 copay(authorization required) |
| Routine chiropractic care | Not covered |
| Acupuncture | $30 copay(limits apply) |
| Foot exams and treatment (Medicare-covered) | $30 copay |
| Routine foot care | $30 copay(limits apply) |
| Dental? | |
| Medicare-covered dental services | $0 copay(authorization required) |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | Not covered |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | $0 copay |
| Other preventive dental services | $0 copay |
| Restorative services (fillings, crowns) | Not covered |
| Endodontics (root canals) | Not covered |
| Periodontics (gum disease) | Not covered |
| Dentures and other removable prosthodontics | Not covered |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Not covered |
| Oral and maxillofacial surgery | Not covered |
| Orthodontics | Not covered |
| Adjunctive general services | Not covered |
| 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 | $150 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 | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $0 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aid plan limit | $1,000 plan limit every three years |
| Hearing aids (all types) | $0 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 | Not covered |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | Not covered |
| 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) | Not covered |
| 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 | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2027). 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 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $5.00 |
| Tier 3 · Preferred Brand | 25% |
| Tier 4 · Non-Preferred Drug | 35% |
| Tier 5 · Specialty Tier | 30% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $5.00 | $5.00 | $5.00 | $10.00 | $10.00 | $10.00 |
| Tier 3: Preferred Brand | 25% | 25% | 25% | 15% | 15% | 15% |
| Tier 4: Non-Preferred Drug | 35% | 35% | 35% | 35% | 35% | 35% |
| Tier 5: Specialty Tier | 30% | 30% | 30% | n/a | n/a | n/a |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Also available in 2 other ID counties
Benefits in plain text
St. Luke's Advantage Rx 01 (HMO) (H3012-001-0) is a 2027 HMO Medicare Advantage plan offered by St. Luke's Health Plan, available to residents of Ada County, ID.
The monthly premium is $77.00.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $31.50.
The in-network deductible for health services is $250.00.
Its in-network out-of-pocket maximum is $5,950.00.
The drug deductible is $299.00. Tier 1 and 2 exempt.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $5.00; tier 3 (Preferred Brand): 25%; tier 4 (Non-Preferred Drug): 35%; tier 5 (Specialty Tier): 30%.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.