2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Anthem Medicare Preferred Select (PPO) | ||||
Location: | Hancock, Ohio Click to see other locations | ||||
Plan ID: | H5529 - 004 - 0 Click to see other plans | ||||
Member Services: | 1-800-467-1199 TTY users 1-888-853-7754 | ||||
— 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 |
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Email a copy of the Anthem Medicare Preferred Select (PPO) benefit details
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— Medicare Plan Features — | |||||
Monthly Premium: | $55.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 | ||||
Annual Initial Coverage Limit (ICL): | $2,840 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,800 | ||||
Additional Gap Coverage? | Many Generics | ||||
Total Number of Formulary Drugs: | 4,499 drugs | Browse the Anthem Medicare Preferred Select (PPO) Formulary | |||
This plan has 6 drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $7.00 | $43.00 | $85.00 | 33% | 33% |
• Number of Drugs per Tier: | 1617 | 563 | 1426 | 554 | 339 |
Plan's Pharmacy Search: | http://www.anthem.com | ||||
Number of Members enrolled in this plan in (H5529 - 004): | 11,094 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 | |||||
$55 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. | |||||
$3 800 out-of-pocket limit. | |||||
There is no limit on cost sharing for the following services: | |||||
In-Network: Supplemental Services:
| |||||
Out-of-Network: Supplemental Services:
| |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. | |||||
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. | |||||
20% of the cost for Part B drugs out-of-network. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.anthem.com on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
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 Anthem Medicare Preferred Select (PPO) 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 Anthem Medicare Preferred Select (PPO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug. | |||||
$0 deductible. | |||||
Supplemental drugs don't count toward your out-of-pocket drug costs. | |||||
You pay the following until total yearly drug costs reach $2 840: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Supplemental Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Supplemental Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Supplemental Drugs | |||||
The plan covers many formulary generics (65%-99% of formulary generic drugs) through the coverage gap. | |||||
You pay the following: | |||||
Tier 1: Generic Drugs | |||||
Tier 6: Supplemental Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 6: Supplemental Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 6: Supplemental Drugs | |||||
After your total yearly drug costs reach $2 840 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for 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 following: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Supplemental Drugs | |||||
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 Anthem Medicare Preferred Select (PPO). | |||||
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: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Supplemental Drugs | |||||
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 for these drugs purchased out-of-network up to the full cost of the drug minus the following: | |||||
Tier 1: Generic Drugs | |||||
Tier 6: Supplemental Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
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 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 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 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 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 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 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 the following: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Supplemental Drugs | |||||
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 | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. | |||||
$0 copay for routine exams. | |||||
Vision Services | |||||
$100 plan coverage limit for eye exams every year. | |||||
$125 plan coverage limit for eye wear every year. | |||||
$25 copay for eye exams. | |||||
$0 to $25 copay for eye wear. | |||||
Dental Services | |||||
$0 copay for Medicare-covered dental benefits. | |||||
20% of the cost for preventive dental benefits. | |||||
$0 copay for comprehensive dental benefits. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$55 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. | |||||
$3 800 out-of-pocket limit. | |||||
There is no limit on cost sharing for the following services: | |||||
In-Network: Supplemental Services:
| |||||
Out-of-Network: Supplemental Services:
| |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. | |||||
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: $200 copay per day | |||||
Days 6 - 90: $0 copay per day | |||||
$0 copay for additional hospital days | |||||
$1 000 out-of-pocket limit every year. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
For hospital stays: | |||||
Days 1 - 5: $275 copay per day | |||||
Days 6 and beyond: $0 copay per day | |||||
Inpatient Mental Health Care | |||||
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 5: $200 copay per day | |||||
Days 6 - 90: $0 copay per day | |||||
$0 copay for additional hospital days | |||||
The maximum out-of-pocket limit is covered under 'Inpatient Hospital Care'. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
For hospital stays: | |||||
Days 1 - 5: $275 copay per day | |||||
Days 6 and beyond: $0 copay per day | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For SNF stays: | |||||
Days 1 - 20: $0 copay per day | |||||
Days 21 - 100: $115 copay per day | |||||
25% of the cost for each SNF stay. | |||||
Home Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for each Medicare-covered home health visit. | |||||
$0 copay for home health visits. | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. | |||||
$10 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$20 copay for each in-area network urgent care Medicare-covered visit. | |||||
$20 copay for each specialist visit for Medicare-covered benefits. | |||||
$15 copay for each primary care doctor visit. | |||||
$25 copay for each specialist visit. | |||||
Chiropractic Services | |||||
Authorization rules may apply. | |||||
$10 copay 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. | |||||
$25 copay for chiropractic benefits. | |||||
Podiatry Services | |||||
$20 copay for each Medicare-covered visit. | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
$25 copay for podiatry benefits. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$40 copay for each Medicare-covered individual or group therapy visit. | |||||
$50 copay for Mental Health benefits. | |||||
$50 copay for Mental Health benefits with a psychiatrist. | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$40 copay for Medicare-covered individual or group visits. | |||||
$50 copay for outpatient substance abuse benefits. | |||||
Outpatient Hospital Services | |||||
Authorization rules may apply. | |||||
$175 copay for each Medicare-covered ambulatory surgical center visit. | |||||
$20 to $175 copay for each Medicare-covered outpatient hospital facility visit. | |||||
$225 copay for ambulatory surgical center benefits. | |||||
$25 to $225 copay for outpatient hospital facility benefits. | |||||
Emergency Care | |||||
$50 copay for Medicare-covered emergency room visits. | |||||
Worldwide coverage. | |||||
If you are admitted to the hospital within 72-hour(s) for the same condition you pay $0 for the emergency room visit | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$20 to $40 copay for Medicare-covered Occupational Therapy visits. | |||||
$20 to $40 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
$0 copay for Medicare-covered Cardiac Rehab services. | |||||
$25 to $50 copay for Occupational Therapy benefits. | |||||
$25 to $50 copay Physical and/or Speech and Language Therapy visits. | |||||
$0 copay for Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered items. | |||||
25% of the cost for durable medical equipment. | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered items. | |||||
25% of the cost for prosthetic devices. | |||||
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. | |||||
20% of the cost for Diabetes self-monitoring training. | |||||
20% of the cost for Nutrition Therapy for Diabetes. | |||||
25% of the cost for Diabetes supplies. | |||||
** Preventive Services ** | |||||
Bone Mass Measurement | |||||
$0 copay for Medicare-covered bone mass measurement. | |||||
$0 copay for Medicare-covered bone mass measurement. | |||||
Colorectal Screening Exams | |||||
$0 copay for Medicare-covered colorectal screenings. | |||||
$0 copay for colorectal screenings. | |||||
Immunizations | |||||
$0 copay for Flu and Pneumonia vaccines. | |||||
No referral needed for Flu and pneumonia vaccines. | |||||
$0 copay for Hepatitis B vaccine. | |||||
$0 copay for immunizations. | |||||
Pap Smears and Pelvic Exams | |||||
$0 copay for Medicare-covered pap smears and pelvic exams | |||||
$0 copay for pap smears and pelvic exams. | |||||
Prostate Cancer Screening Exams | |||||
$0 copay for Medicare-covered prostate cancer screening. | |||||
$0 copay for prostate cancer screening. | |||||
** Additional Benefits ** | |||||
Dialysis | |||||
20% of the cost for renal dialysis | |||||
$0 copay for Nutrition Therapy for End-Stage Renal Disease. | |||||
20% of the cost for renal dialysis. | |||||
20% of the cost 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. | |||||
20% of the cost for Part B drugs out-of-network. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.anthem.com on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
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 Anthem Medicare Preferred Select (PPO) 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 Anthem Medicare Preferred Select (PPO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug. | |||||
$0 deductible. | |||||
Supplemental drugs don't count toward your out-of-pocket drug costs. | |||||
You pay the following until total yearly drug costs reach $2 840: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Supplemental Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Supplemental Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Supplemental Drugs | |||||
The plan covers many formulary generics (65%-99% of formulary generic drugs) through the coverage gap. | |||||
You pay the following: | |||||
Tier 1: Generic Drugs | |||||
Tier 6: Supplemental Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 6: Supplemental Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 6: Supplemental Drugs | |||||
After your total yearly drug costs reach $2 840 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for 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 following: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Supplemental Drugs | |||||
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 Anthem Medicare Preferred Select (PPO). | |||||
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: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Supplemental Drugs | |||||
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 for these drugs purchased out-of-network up to the full cost of the drug minus the following: | |||||
Tier 1: Generic Drugs | |||||
Tier 6: Supplemental Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
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 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 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 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 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 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 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 the following: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Injectable Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Supplemental Drugs | |||||
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 | |||||
$0 copay for Medicare-covered dental benefits. | |||||
20% of the cost for preventive dental benefits. | |||||
$0 copay for comprehensive dental benefits. | |||||
Hearing Services | |||||
Hearing aids not covered. | |||||
$100 plan coverage limit for routine hearing tests every year. | |||||
$25 copay for hearing exams. | |||||
Vision Services | |||||
$100 plan coverage limit for eye exams every year. | |||||
$125 plan coverage limit for eye wear every year. | |||||
$25 copay for eye exams. | |||||
$0 to $25 copay for eye wear. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. | |||||
$0 copay for routine exams. | |||||
Health/Wellness Education | |||||
The plan covers the following health/wellness education benefits: | |||||
$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. | |||||
$0 copay for Health and Wellness services. | |||||
Transportation | |||||
This plan does not cover routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. |