2026 Select (HMO)

Plan Overview

$0 / month

Medical Deductible

This plan does not have any medical deductibles.

Pharmacy Deductible

$250 (Applies to drugs in Tiers 3, 4 and 5)

Coverage Details

Virginia counties: Alexandria City, Arlington, Fairfax, Fairfax City, Falls Church City, Loudoun, Manassas City and Prince William.

Medical

Medical Deductible	This plan does not have any medical deductibles.
Primary Care Provider Visit	$0 copay
Specialist Visit	$30 copay
Referrals	Not required.
Urgent Care	$40 copay The copay is not waived if you are admitted to the hospital.
Telehealth	$0 copay
Outpatient Surgery	$250 copay
Emergency Care	$115 copay The copay is waived if you are admitted to the hospital within 24 hours for the same condition.
Worldwide Emergency & Urgently Needed Services	$115 copay for emergency care services and $40 copay for emergency care services. Inpatient care is not covered.
Inpatient Hospital Stay	$350/day copay for days 1-5; $0 copay for days 6-90; Medicare allows 60 “lifetime reserve” days.
Podiatry Services	Medicare-covered podiatry care: $30 copay Non-Medicare covered podiatry care: $0 copay (combined benefit up to 24 times per year with non-Medicare covered acupuncture and non-Medicare covered chiropractic)
Acupuncture	Medicare-covered Acupuncture: $0 – $30 copay, based on location of service. Non-Medicare covered Acupuncture: $0 copay (up to 24 combined visits per year for non-Medicare covered acupuncture, Routine Foot Care, and Non-Medicare covered chiropractic).
Chiropractic Services	Medicare-covered chiropractic care: $15 copay Non-Medicare covered chiropractic care: $0 copay (up to 24 combined visits per year for Routine Foot Care, Non-Medicare covered chiropractic, and non-Medicare covered acupuncture).
Hearing Services Learn more	$0 copay for diagnostic hearing exams $0 copay for routine hearing exams $0 copay for fitting and evaluation for hearing aids $399 copay per hearing aid for Advanced hearing aids OR $699 copay per aid for Premium hearing aids. Up to two TruHearing-branded hearing aids each year (one per ear per year).”
Silver&Fit® Program Learn more	$0 copay for participating fitness centers.
Prescription
Pharmacy Deductible	$250 (Applies to drugs in Tiers 3, 4 and 5)
Preferred Generic (Tier 1)	$0 copay for a one-month supply $0 copay for a two-month supply $0 copay for a three-month supply
Generic (Tier 2)	$10 for a one-month supply $15 for a two-month supply $20 for a three-month supply
Preferred Brand (Tier 3)	25% ($35 for Select Insulins) for a one-month supply 25% ($70 for Select Insulins) for a two-month supply 25% ($105 for Select Insulins) for a three-month supply
Non-Preferred Drug (Tier 4)	25% ($35 for Select Insulins) for a one-month supply 25% ($70 for Select Insulins) for a two-month supply 25% ($105 for Select Insulins) for a three-month supply
Specialty Tier (Tier 5)	30% of the total cost of a one-month supply (long-term supply is not available)
Mail Order	Available
Vision
Medicare-covered exam to diagnose and treat diseases and conditions of the eye	$50 copay
Yearly Glaucoma Screening	$0 copay
Routine Eye Exam	$0 copay
Eyeglasses or Contact Lenses after Cataract Surgery	$0 copay
Routine Eyewear	Our plan pays up to $400 every year for supplemental eyewear from any in-network Superior Vision provider.
Dental
Medicare-covered Dental Services	$0 copay
Preventive Dental Services	Cleaning(s) (2 cleanings per year): $0 copay Oral exam(s) (Frequency determined by type of oral exam): $0 copay Dental X-Ray(s) (Frequency determined by type of X-Ray): $0 copay
Fluoride Treatments	Fluoride treatments (2 fluoride treatments per year): $0 copay
Comprehensive Dental Services	The plan has a maximum coverage amount of $2,400 per year for in-network non-Medicare-covered comprehensive dental services. Members are responsible for the difference between the allowed amount and the billed amount for any out-of-network services.
Optional Supplemental Benefits	Not Available
Restorative services (such as inlays, onlays, crowns, resin restoration, etc.)	Frequency dependent on procedure. In-network: $0 copay
Endodontics	Frequency dependent on procedure. In-network: $0 copay
Periodontics	Frequency dependent on procedure. In-network: $0 copay
Extractions	Frequency dependent on procedure. In-network: $0 copay
Documents
2026 Summary of Benefits Select (HMO) 2026 Evidence of Coverage Select (HMO) – English \| Spanish 2026 Annual Notice of Changes Select (HMO) – English \| Spanish 2026 Select (HMO) LIS Premium Summary Chart – English \| Spanish Pre-Enrollment Checklist – English \| Spanish

2027 Plans

Johns Hopkins Advantage MD (HMO) has an in-network out-of-pocket maximum of $8,950. Johns Hopkins Advantage MD Tribute (HMO) has an in-network out-of-pocket maximum of $7,200. Johns Hopkins Advantage MD (PPO) has an in-network out-of-pocket maximum of $7,950 and a combined in- and out-of-network maximum of $11,300. Johns Hopkins Advantage MD Plus (PPO) has an in-network out-of-pocket maximum of $7,550 and a combined in- and out-of-network maximum of $11,300. Johns Hopkins Advantage MD Access (PPO) has an in-network out-of-pocket maximum of $8,000 and a combined in- and out-of-network maximum of $11,300. Johns Hopkins Advantage MD BMORE Balanced (HMO-DSNP) and Johns Hopkins Advantage MD D-SNP (HMO) has an in-network out-of-pocket maximum of $9,850. Johns Hopkins Advantage MD Select (HMO) has an in-network out-of-pocket maximum of $9,250.

For out-of-network benefits, you pay a percentage for most covered services.

Limitations: 1. Members are responsible for the difference between the allowed amount and the billed amount. For more information, please review the Evidence of Coverage. 2. Johns Hopkins Advantage MD BMORE Balanced (HMO-DSNP) and Johns Hopkins Advantage MD Access (PPO) have a $1,000 allowance for comprehensive dental services added to your Flex Card. Johns Hopkins Advantage MD D-SNP (HMO) has $1,000 annual maximum for comprehensive dental services. Johns Hopkins Advantage MD Select (HMO) has $1,500 annual maximum for comprehensive dental services. Johns Hopkins Advantage MD Tribute (HMO) has $2,000 annual maximum for comprehensive dental services.

Prior authorizations may be required for some services, contact Member Services for more details.

2026 Plans

Johns Hopkins Advantage MD (HMO) has an in-network out-of-pocket maximum of $8,950. Johns Hopkins Advantage MD Tribute (HMO) has an in-network out-of-pocket maximum of $6,800. Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO), Johns Hopkins Advantage MD Primary (PPO) have an in-network out-of-pocket maximum of $7,550 and a combined in- and out-of-network maximum of $11,300. Johns Hopkins Advantage MD D-SNP (HMO) has an in-network out-of-pocket maximum of $9,250. Johns Hopkins Advantage MD Select (HMO) has an in-network out-of-pocket maximum of $9,250

For out-of-network benefits, you pay a percentage for most covered services.

Limitations: 1. Members are responsible for the difference between the allowed amount and the billed amount. For more information, please review the Evidence of Coverage. 2. The comprehensive dental benefit for the Optional Supplement benefits for the Johns Hopkins Advantage MD (HMO), Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO), and Johns Hopkins Advantage MD Primary (PPO) plan has a $1,000 Annual Maximum. The comprehensive dental benefit for the Johns Hopkins Advantage MD Tribute (HMO) and Johns Hopkins Advantage MD D-SNP (HMO) has a $2,000 Annual Maximum. The comprehensive dental benefit for the Johns Hopkins Advantage MD Select (HMO) has a $2,400 Annual Maximum.

Prior authorizations are required for the following: endodontics, general anesthesia when medically necessary and administered in connection with oral or dental surgery, oral surgery, periodontics, bridges, crowns, inlays, onlays, and dentures (full or partial).

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2026 Select (HMO)

Plan Overview

Coverage Details

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