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2011 Medicare Advantage Plan Benefit Details for the AARP MedicareComplete Plus (HMO-POS) - H3456-001-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2011 Medicare Advantage Plan Details
Medicare Plan Name:AARP MedicareComplete Plus (HMO-POS)
Location:Person, North Carolina     Click to see other locations
Plan ID:H3456 - 001 - 0     Click to see other plans
Member Services:1-800-643-4845 TTY users 711
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the AARP MedicareComplete Plus (HMO-POS) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$2,840
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$4,750
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,685 drugsBrowse the AARP MedicareComplete Plus (HMO-POS) Formulary
This plan has 4 drug tiers. See cost-sharing highlights below.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$5.00$45.00$85.0033% 
• Number of Drugs per
  Tier:		14151070759441
Plan's Pharmacy Search:http://www.PrescriptionSolutions.com
Number of Members enrolled in this plan in (H3456 - 001):68,562 members
— Plan Premium Details —
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Cost **
Premium and Other Important Information
$0 monthly plan premium in addition to your monthly Medicare Part B premium.
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
This plan covers all Medicare-covered preventive services with zero cost sharing.
$4 750 out-of-pocket limit.
This limit includes only Medicare-covered services.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
No referral required for network doctors specialists and hospitals.
Plan covers you when you travel in the U.S.
** Extra Benefits **
Prescription Drugs
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.SecureHorizons.com/ourplans/searchformulary.html on the web.
Different out-of-pocket costs may apply for people who
  • have limited incomes
  • live in long term care facilities or
  • have access to Indian/Tribal/Urban (Indian Health Service).
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
Total yearly drug costs are the total drug costs paid by both you and the plan.
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
Some drugs have quantity limits.
Your provider must get prior authorization from AARP MedicareComplete Plus (HMO-POS) for certain drugs.
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.
If you request a formulary exception for a drug and AARP MedicareComplete Plus (HMO-POS) approves the exception you will pay Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs cost sharing for that drug.
$0 deductible.
You pay the following until total yearly drug costs reach $2 840:
Tier 1: Preferred Generic Drugs
Tier 2: Generic and Preferred Brand Drugs
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (31-day) supply of drugs in this tier
  • $45 copay for a one-month (31-day) supply of drugs in this tier
  • $85 copay for a one-month (31-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier
  • $15 copay for a three-month (90-day) supply of drugs in this tier
  • $135 copay for a three-month (90-day) supply of drugs in this tier
  • $255 copay for a three-month (90-day) supply of drugs in this tier
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier
    • Tier 1: Preferred Generic Drugs
    Tier 2: Generic and Preferred Brand Drugs
    Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (31-day) supply of drugs in this tier
  • $45 copay for a one-month (31-day) supply of drugs in this tier
  • $85 copay for a one-month (31-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier
    • Tier 1: Preferred Generic Drugs
    Tier 2: Generic and Preferred Brand Drugs
    Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $10 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $125 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $245 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $15 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $255 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
    • After your total yearly drug costs reach $2 840 you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 550.
    After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of:
    • A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
    • 5% coinsurance.
    Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from AARP MedicareComplete Plus (HMO-POS).
    You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840:
    Tier 1: Preferred Generic Drugs
    Tier 2: Generic and Preferred Brand Drugs
    Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (31-day) supply of drugs in this tier
  • $45 copay for a one-month (31-day) supply of drugs in this tier
  • $85 copay for a one-month (31-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier
    • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550.
    You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550.
    You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of:
    • A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
    • 5% coinsurance.
    You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    Physical Exams
    When you get Medicare Part B you can get a one-time physical within the first 12 months of your new Part B coverage. The coverage does not include lab tests.
    $0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits.
    Vision Services
  • $0 copay for one pair of eyeglasses or contact lenses after cataract surgery.
  • $0 to $40 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $40 copay for up to 1 routine eye exam(s) every year
    • Dental Services
    In general preventive dental benefits (such as cleaning) not covered.
    $40 copay for Medicare-covered dental benefits.
    ** Important Information **
    Premium and Other Important Information
    $0 monthly plan premium in addition to your monthly Medicare Part B premium.
    Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
    This plan covers all Medicare-covered preventive services with zero cost sharing.
    $4 750 out-of-pocket limit.
    This limit includes only Medicare-covered services.
    Doctor and Hospital Choice
    No referral required for network doctors specialists and hospitals.
    Plan covers you when you travel in the U.S.
    ** Inpatient Care **
    Inpatient Hospital Care (Acute)
    No limit to the number of days covered by the plan each benefit period.
    For Medicare-covered hospital stays:
    Days 1 - 5: $290 copay per day
    Days 6 - 90: $0 copay per day
    $0 copay for each additional hospital day.
    Inpatient Mental Health Care
    You get up to 190 days in a Psychiatric Hospital in a lifetime.
    For Medicare-covered hospital stays:
    Days 1 - 5: $290 copay per day
    Days 6 - 90: $0 copay per day
    Skilled Nursing Facility (SNF)
    Plan covers up to 100 days each benefit period
    No prior hospital stay is required.
    For Medicare-covered SNF stays:
    Days 1 - 20: $50 copay per day
    Days 21 - 58: $100 copay per day
    Days 59 - 100: $0 copay per day
    Home Health Care
    $0 copay for each Medicare-covered home health visit.
    Hospice
    You must get care from a Medicare-certified hospice.
    ** Outpatient Care **
    Doctor Office Visits
    $20 copay for each primary care doctor visit for Medicare-covered benefits.
    $30 copay for each in-area network urgent care Medicare-covered visit.
    $40 copay for each specialist visit for Medicare-covered benefits.
    Chiropractic Services
    50% of the cost for each Medicare-covered visit.
    Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.
    Podiatry Services
    $40 copay for each Medicare-covered visit.
    $40 copay for up to 6 routine visit(s) every year
    Medicare-covered podiatry benefits are for medically-necessary foot care.
    Outpatient Mental Health Care
    $40 copay for each Medicare-covered individual therapy visit.
    $30 copay for each Medicare-covered group therapy visit.
    Outpatient Substance Abuse Care
    $40 copay for Medicare-covered individual visits.
    $30 copay for Medicare-covered group visits.
    Outpatient Hospital Services
    20% of the cost for each Medicare-covered ambulatory surgical center visit.
    20% of the cost for each Medicare-covered outpatient hospital facility visit.
    Emergency Care
    $50 copay for Medicare-covered emergency room visits.
    Worldwide coverage.
    If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit
    Outpatient Rehabilitation Services
    $40 copay for Medicare-covered Occupational Therapy visits.
    $40 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.
    $40 copay for Medicare-covered Cardiac Rehab services.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    20% of the cost for Medicare-covered items.
    Prosthetic Devices
    20% of the cost for Medicare-covered items.
    Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies
    $0 copay for Diabetes self-monitoring training.
    $0 copay for Nutrition Therapy for Diabetes.
    $0 copay for Diabetes supplies.
    ** Preventive Services **
    Bone Mass Measurement
    $0 copay for Medicare-covered bone mass measurement.
    Colorectal Screening Exams
    $0 copay for Medicare-covered colorectal screenings.
    $0 copay up to 1 additional screening(s) every year.
    Immunizations
    $0 copay for Flu and Pneumonia vaccines.
    No referral needed for Flu and pneumonia vaccines.
    $0 copay for Hepatitis B vaccine.
    Pap Smears and Pelvic Exams
    $0 copay for Medicare-covered pap smears and pelvic exams
    $0 copay up to 1 additional pap smear(s) and pelvic exam(s) every year
    Prostate Cancer Screening Exams
    $0 copay for Medicare-covered prostate cancer screening.
    ** Additional Benefits **
    Dialysis
    20% of the cost for renal dialysis
    $0 copay for Nutrition Therapy for End-Stage Renal Disease.
    Prescription Drugs
    20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.
    This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.SecureHorizons.com/ourplans/searchformulary.html on the web.
    Different out-of-pocket costs may apply for people who
    • have limited incomes
    • live in long term care facilities or
    • have access to Indian/Tribal/Urban (Indian Health Service).
    The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
    Total yearly drug costs are the total drug costs paid by both you and the plan.
    The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
    Some drugs have quantity limits.
    Your provider must get prior authorization from AARP MedicareComplete Plus (HMO-POS) for certain drugs.
    You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
    If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.
    If you request a formulary exception for a drug and AARP MedicareComplete Plus (HMO-POS) approves the exception you will pay Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs cost sharing for that drug.
    $0 deductible.
    You pay the following until total yearly drug costs reach $2 840:
    Tier 1: Preferred Generic Drugs
    Tier 2: Generic and Preferred Brand Drugs
    Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (31-day) supply of drugs in this tier
  • $45 copay for a one-month (31-day) supply of drugs in this tier
  • $85 copay for a one-month (31-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier
  • $15 copay for a three-month (90-day) supply of drugs in this tier
  • $135 copay for a three-month (90-day) supply of drugs in this tier
  • $255 copay for a three-month (90-day) supply of drugs in this tier
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier
    • Tier 1: Preferred Generic Drugs
    Tier 2: Generic and Preferred Brand Drugs
    Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (31-day) supply of drugs in this tier
  • $45 copay for a one-month (31-day) supply of drugs in this tier
  • $85 copay for a one-month (31-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier
    • Tier 1: Preferred Generic Drugs
    Tier 2: Generic and Preferred Brand Drugs
    Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $10 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $125 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $245 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $15 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $255 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
    • After your total yearly drug costs reach $2 840 you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 550.
    After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of:
    • A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
    • 5% coinsurance.
    Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from AARP MedicareComplete Plus (HMO-POS).
    You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840:
    Tier 1: Preferred Generic Drugs
    Tier 2: Generic and Preferred Brand Drugs
    Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (31-day) supply of drugs in this tier
  • $45 copay for a one-month (31-day) supply of drugs in this tier
  • $85 copay for a one-month (31-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier
    • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550.
    You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550.
    You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of:
    • A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
    • 5% coinsurance.
    You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    Dental Services
    In general preventive dental benefits (such as cleaning) not covered.
    $40 copay for Medicare-covered dental benefits.
    Hearing Services
  • $40 copay for Medicare-covered diagnostic hearing exams
  • $0 to $40 copay for up to 1 routine hearing test(s) every year
  • $0 copay per hearing aid
    • $300 plan coverage limit for hearing aids every two years.
    Vision Services
  • $0 copay for one pair of eyeglasses or contact lenses after cataract surgery.
  • $0 to $40 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $40 copay for up to 1 routine eye exam(s) every year
    • Physical Exams
    When you get Medicare Part B you can get a one-time physical within the first 12 months of your new Part B coverage. The coverage does not include lab tests.
    $0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits.
    Health/Wellness Education
    The plan covers the following health/wellness education benefits:
  • Written health education materials including Newsletters
  • Health Club Membership/Fitness Classes
  • Nursing Hotline
    • $0 copay for each Medicare-covered smoking cessation counseling session.
    $0 copay for each Medicare-covered HIV screening.
    HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.
    Transportation
    This plan does not cover routine transportation.
    Acupuncture
    This plan does not cover Acupuncture.
    Point of Service
    Point of Service coverage is available for the following benefits:
    • Inpatient Hospital Acute
    • Inpatient Hospital Psychiatric
    • Skilled Nursing Facility (SNF)
    • Comprehensive Outpatient Rehabilitation Facility (CORF)
    • Partial Hospitalization
    • Home Health Services
    • Primary Care Physician Services
    • Chiropractic Services
    • Occupational Therapy Services
    • Physician Specialist Services
    • Mental Health Specialty Services
    • Podiatry Services
    • Other Health Care Professional
    • Psychiatric Services
    • Physical Therapy and Speech/Language Pathology Services
    • Outpatient Diag Procs/Tests/Lab Services
    • Diagnostic Radiological Services
    • Therapeutic Radiological Services
    • Outpatient X-Rays
    • Outpatient Hospital Services
    • Ambulatory Surgical Center (ASC) Services
    • Outpatient Substance Abuse
    $7 500 out-of-pocket limit every year for POS benefits
    For hospital stays:
    Days 1 - 22: $350 copay per day
    Days 23 and beyond: $0 copay per day
    For Inpatient Psychiatric Hospital stays:
    Days 1 - 22: $350 copay per day
    Days 23 - 90: $0 copay per day
    For each SNF stay:
    Days 1 - 43: $175 copay per SNF day
    Days 44 - 100: $0 copay per SNF day
    $25 copay for
    • Primary Care Physician Services
    • Other Health Care Professional
    • Routine Physical Exams
    $45 copay for
    • Comprehensive Outpatient Rehabilitation Facility (CORF)
    • Occupational Therapy Services
    • Physician Specialist Services
    • Podiatry Services
    • Physical Therapy and Speech/Language Pathology Services
    • Cardiac Rehabilitation Services
    • Comprehensive Dental
    • Eye Exams
    • Hearing Exams
    30% of the cost for
    • Home Health Services
    • Diagnostic Radiological Services
    • Therapeutic Radiological Services
    • Outpatient Hospital Services
    • Ambulatory Surgical Center (ASC) Services
    • DME
    • Prosthetics/Medical Supplies
    • Diabetes Monitoring Supplies
    • Pap Smears and Pelvic Exams
    • Prostate Screening
    • Colorectal Screening
    • Bone Mass Measurement
    • Mammography Screening
    • Diabetes Monitoring
    • Nutrition Therapy for Diabetes and Renal Disease
    • Eye Wear
    $10 copay [or 30% of the cost] for
    • Outpatient Diag Procs/Tests/Lab Services
    $21 copay for
    • Outpatient X-Rays
    $75 copay for
    • Partial Hospitalization
    $200 copay for
    • Ambulance Services
    $35 to $45 copay for
    • Mental Health Specialty Services
    • Psychiatric Services
    • Outpatient Substance Abuse
    $0 copay for
    • Blood
    • Health Education/Wellness
    • Immunizations
    50% of the cost for
    • Chiropractic Services
    ** Cost **
    Premium and Other Important Information
    Package: 1 - Dental Platinum Rider:
    $32 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    ** Extra Benefits **
    Dental Services
    Plan offers additional comprehensive dental benefits.
  • $0 copay for up to 1 cleaning(s) every six months
  • $0 copay for up to 1 fluoride treatment(s) every six months
  • $0 copay for up to 1 oral exam(s) every six months
  • $0 copay for up to 1 dental x-ray(s)
    • $1 000 plan coverage limit for dental benefits every year.
    ** Important Information **
    Premium and Other Important Information
    Package: 1 - Dental Platinum Rider:
    $32 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    ** Additional Benefits **
    Dental Services
    Plan offers additional comprehensive dental benefits.
  • $0 copay for up to 1 cleaning(s) every six months
  • $0 copay for up to 1 fluoride treatment(s) every six months
  • $0 copay for up to 1 oral exam(s) every six months
  • $0 copay for up to 1 dental x-ray(s)
    • $1 000 plan coverage limit for dental benefits every year.




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    • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
    • Limitations, copayments, and restrictions may apply.
    • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
      Statement required by Medicare:
      "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
    • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
    • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
    • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
    • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
    • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
    • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
    • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
    • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
    • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
    • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
    • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
    • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
    • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
    • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
    • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
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