Member Town Hall October 2025
Answers to Questions from the 2026 Plan Year Town Hall.
Member Town Hall Questions and Responses
During the session, members asked a variety of questions about benefits, prescription coverage, plan differences, supplemental services, and more. To make this information easy to review, we’ve compiled all the questions and answers discussed during the event.
Prescription Drugs & Pharmacy Coverage
How will prescription costs change from having Plus (PPO) to PPO?
For the 2026 plan year, the prescription drug deductible, tiers and cost shares are the same between the standard PPO and the Plus (PPO) plans. The formulary (list of covered drugs) for both plans is also the same.
Why do I have to always have generic prescriptions?
We encourage members to use generic medications whenever possible because they offer the same active ingredients and clinical benefits as brand-name drugs, but at a lower cost. This helps keep prescription costs affordable. However, if you and your prescriber determine that a generic medication isn’t appropriate for your specific needs, you can request an exception for the brand-name drug by contacting Member Services at PPO: 877-293-5328 or HMO: 877-293-4998.
Why am I unable to obtain the prescription that my doctor has provided?
We understand it can be frustrating when you’re unable to get a prescription your doctor has ordered. While we aim to cover a wide range of medications, our formulary follows evidence-based guidelines to ensure safe, effective, and affordable treatment options. Some prescriptions may require prior authorization, quantity limits, or step therapy before they can be filled. If you and your prescriber determine that a medication not on our formulary is medically necessary, you can request a formulary exception by contacting Member Services at PPO: 877-293-5328 or HMO: 877-293-4998.
Is there a generic for Xarelto?
Yes, there is a generic version of Xarelto available, called rivaroxaban. It is included on our 2026 formulary. Talk with your provider or pharmacist to see if rivaroxaban is right for you and to discuss any cost savings or coverage differences compared to the brand-name medication.
Will the over-the-counter (OTC) benefit be included for plan year 2026?
The OTC benefit is included in the Advantage MD HMO, HMO D-SNP, Tribute (HMO) and Select (HMO) plans for 2026. OTC allowances vary by plan type. Some 2025 plans had the OTC benefit and will not have the benefit for 2026. We understand that changes to your coverage can be an adjustment, and we work each year to keep plans consistent and competitive. If the OTC allowance is a benefit that is important to you, please call 888-403-7682 to speak with a Medicare specialist who can guide you through your Advantage MD plan options. You can also visit HopkinsMedicare.com to browse our full plan offerings for your area. Remember: if you want to select a new Advantage MD plan, the annual enrollment period ends Dec. 7.
I have had a problem accessing the OTC benefit. How can I do this?
We want all benefits and services to be easy to access and use. If you have issues accessing or using any of your benefits, please call our Member Services team at PPO: 877-293-5328 or HMO: 877-293-4998. They will guide you through the process to ensure you are able to access the benefits available to you.
Understanding Plan Types (HMO, PPO & Coverage Differences)
What is the difference between HMO and PPO in 2026?
The primary difference between HMO and PPO plans is flexibility in accessing care. HMO plans require you to see in-network providers only and generally require you to select a primary care provider, although HMO members are not required to get referrals to see a specialist. With Advantage MD’s extensive network of providers, staying in-network isn’t a concern for many members. With PPO plans, you have out-of-network coverage (please note that you may have high costs when using out-of-network providers) and you do not need referrals. All plans also offer different benefits and different coverage amounts. You can compare all Advantage MD plans at HopkinsMedicare.com to see the full list of differences.
What is the cost difference between HMO and PPO?
Premiums and cost-shares vary between our seven plan types. Please visit HopkinsMedicare.com to browse our full plan offerings for your area and review cost comparisons. Remember: if you want to select a new Advantage MD plan, the annual enrollment period ends Dec. 7.
Will costs for my health plan and health care be affected by the current governmental issues?
While external factors can impact health care costs, we strive to keep our pricing stable for our members. Plan benefits and costs for 2026 are set and will not change.
Dental, Vision & Hearing Benefits
How can one get dental coverage when not on it before?
Some Advantage MD plan types (HMO D-SNP, Tribute (HMO) and Select (HMO) include a comprehensive dental allowance. All other plan types offer supplemental comprehensive dental coverage for an additional $23/month. In 2026, you must purchase this additional coverage before the end of January; you will not be able to enroll in comprehensive dental coverage throughout the year. Please call our Member Services team at PPO: 877-293-5328 or HMO: 877-293-4998 to learn more about or purchase the comprehensive dental coverage for 2026.
Is there a program to help afford hearing aids if I need them? Do I pay an extra premium for hearing coverage?
All Advantage MD plan types except for Advantage MD Primary (PPO) include hearing aid coverage as part of the standard premium. All other plan types offer hearing aids at a copay, which varies by plan. Coverage is provided through TruHearing. For detailed information, please visit HopkinsMedicare.com/members or contact customer service at PPO: 877-293-5328 or HMO: 877-293-4998, for clarification.
How can I use my benefits for eyeglasses?
All Advantage MD plans provide members with an allowance for eyewear, from $150/year up to $400/year, depending on the plan type. To use your allowance, provide your member ID card at the time of purchase. Be sure to always confirm that your provider is in-network prior to your appointment.
If you need more specific instructions, please call Member Services.
Are refraction eye exams covered under my plan? What’s included in my vision benefit?
Most of our plans cover one routine eye exam per year. To verify your vision benefits, please call Member Services at PPO: 877-293-5328 or HMO: 877-293-4998.
Telehealth, Fitness & Wellness Programs
Is telehealth covered?
Yes, Advantage MD covers telehealth, including our $0, 24/7 urgent care telehealth platform. Members also have access to a 24/7 Nurse Chat to speak with a registered nurse anytime, also for $0. Learn more about telehealth services.
Does Advantage MD offer access to fitness programs?
Advantage MD offers a variety of fitness benefits. All members can sign up for Silver&Fit®, a program that gives you $0 access to participating fitness centers or one Home Fitness Kit per year, if you prefer to work out from home. We also offer many online health education classes at no additional cost to our members. View more information about our fitness programs.
Member Services & Support
What are you doing to educate the call center about approved procedures?
We continuously train our Member Services representatives to ensure you receive the best support each and every time you call.
How can I speak with Member Services?
For assistance, please contact Member Services at PPO: 877-293-5325 or HMO: 877-293-4998. Please call us first when you have a question, concern or issue, and we will be happy to assist you.
