** Cost ** |
Premium and Other Important Information |
$170.3 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. |
$3 000 out-of-pocket limit. |
All plan services included. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. |
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 http://www.medica.com/C12/DrugFormularyPartD/default.aspx 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 Medica Prime Solution Enhanced w/Standard Rx - WI (Cost) 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 Medica Prime Solution Enhanced w/Standard Rx - WI (Cost) approves the exception you will pay Tier 3: 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: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$10 copay for a one-month (31-day) supply of drugs in this tier |
$34 copay for a one-month (31-day) supply of drugs in this tier |
$74 copay for a one-month (31-day) supply of drugs in this tier |
25% coinsurance for a one-month (31-day) supply of drugs in this tier |
$30 copay for a three-month (90-day) supply of drugs in this tier |
$102 copay for a three-month (90-day) supply of drugs in this tier |
$222 copay for a three-month (90-day) supply of drugs in this tier |
25% coinsurance for a three-month (90-day) supply of drugs in this tier |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$10 copay for a one-month (31-day) supply of drugs in this tier |
$34 copay for a one-month (31-day) supply of drugs in this tier |
$74 copay for a one-month (31-day) supply of drugs in this tier |
25% coinsurance for a one-month (31-day) supply of drugs in this tier |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$20 copay for a three-month (90-day) supply of drugs in this tier |
$68 copay for a three-month (90-day) supply of drugs in this tier |
$148 copay for a three-month (90-day) supply of drugs in this tier |
25% coinsurance for a three-month (90-day) supply of drugs in this tier |
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 Medica Prime Solution Enhanced w/Standard Rx - WI (Cost). |
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: Specialty Tier Drugs |
$10 copay for a one-month (31-day) supply of drugs in this tier |
$34 copay for a one-month (31-day) supply of drugs in this tier |
$74 copay for a one-month (31-day) supply of drugs in this tier |
25% coinsurance for a one-month (31-day) supply of drugs in this tier |
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. |
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.
|
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
Vision Services |
$0 copay for diagnosis and treatment for diseases and conditions of the eye |
and up to 1 routine eye exam(s) every year |
$30 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 copay for glasses |
$0 copay for contacts |
$125 plan coverage limit for eye wear every two years. |
Dental Services |
$0 copay for Medicare-covered dental benefits. |
In general preventive dental benefits (such as cleaning) not covered. |
** Important Information ** |
Premium and Other Important Information |
$170.3 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. |
$3 000 out-of-pocket limit. |
All plan services included. |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. |
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. |
$0 copay |
Inpatient Mental Health Care |
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. |
$0 copay |
Skilled Nursing Facility (SNF) |
Plan covers up to 100 days each benefit period |
$0 copay for SNF services |
Home Health Care |
$0 copay for Medicare-covered 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. |
$0 copay for each primary care doctor visit for Medicare-covered benefits. |
$0 copay for the cost of each in-area network urgent care Medicare-covered visit. |
$0 copay for each specialist doctor visit for Medicare-covered benefits. |
Chiropractic Services |
$0 copay for Medicare-covered chiropractic visits. |
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 |
$0 copay for Medicare-covered podiatry benefits. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
$0 copay for Medicare-covered Mental Health visits. |
Outpatient Substance Abuse Care |
$0 copay for Medicare-covered visits. |
Outpatient Hospital Services |
$0 copay for each Medicare-covered ambulatory surgical center visit. |
$0 copay for each Medicare-covered outpatient hospital facility visit. |
Emergency Care |
$0 copay for Medicare-covered emergency room visits. |
Worldwide coverage. |
Outpatient Rehabilitation Services |
There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits. |
$0 copay for Medicare-covered Occupational Therapy visits. |
$0 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$0 copay for Medicare-covered Cardiac Rehab services. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
$0 copay for Medicare-covered items. |
Prosthetic Devices |
0% 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. |
Immunizations |
$0 copay for Flu and Pneumonia vaccines. |
$0 copay for Hepatitis B vaccine. |
No referral needed for Flu and pneumonia vaccines. |
No referral needed for other immunizations. |
Pap Smears and Pelvic Exams |
$0 copay for Medicare-covered pap smears and pelvic exams |
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 |
Cost plan members pay Fee-for-Service cost sharing for out-of-area dialysis. |
$0 copay 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 http://www.medica.com/C12/DrugFormularyPartD/default.aspx 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 Medica Prime Solution Enhanced w/Standard Rx - WI (Cost) 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 Medica Prime Solution Enhanced w/Standard Rx - WI (Cost) approves the exception you will pay Tier 3: 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: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$10 copay for a one-month (31-day) supply of drugs in this tier |
$34 copay for a one-month (31-day) supply of drugs in this tier |
$74 copay for a one-month (31-day) supply of drugs in this tier |
25% coinsurance for a one-month (31-day) supply of drugs in this tier |
$30 copay for a three-month (90-day) supply of drugs in this tier |
$102 copay for a three-month (90-day) supply of drugs in this tier |
$222 copay for a three-month (90-day) supply of drugs in this tier |
25% coinsurance for a three-month (90-day) supply of drugs in this tier |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$10 copay for a one-month (31-day) supply of drugs in this tier |
$34 copay for a one-month (31-day) supply of drugs in this tier |
$74 copay for a one-month (31-day) supply of drugs in this tier |
25% coinsurance for a one-month (31-day) supply of drugs in this tier |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$20 copay for a three-month (90-day) supply of drugs in this tier |
$68 copay for a three-month (90-day) supply of drugs in this tier |
$148 copay for a three-month (90-day) supply of drugs in this tier |
25% coinsurance for a three-month (90-day) supply of drugs in this tier |
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 Medica Prime Solution Enhanced w/Standard Rx - WI (Cost). |
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: Specialty Tier Drugs |
$10 copay for a one-month (31-day) supply of drugs in this tier |
$34 copay for a one-month (31-day) supply of drugs in this tier |
$74 copay for a one-month (31-day) supply of drugs in this tier |
25% coinsurance for a one-month (31-day) supply of drugs in this tier |
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. |
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.
|
Dental Services |
$0 copay for Medicare-covered dental benefits. |
In general preventive dental benefits (such as cleaning) not covered. |
Hearing Services |
$0 copay for Medicare-covered diagnostic hearing exams |
$0 copay for |
up to 1 routine hearing test(s) every year |
up to 1 fitting-evaluation(s) for a hearing aid every year |
$0 copay for hearing aids. |
$450 plan coverage limit for routine hearing tests and hearing aids every year. |
Vision Services |
$0 copay for diagnosis and treatment for diseases and conditions of the eye |
and up to 1 routine eye exam(s) every year |
$30 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 copay for glasses |
$0 copay for contacts |
$125 plan coverage limit for eye wear every two years. |
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
Health/Wellness Education |
The plan covers the following health/wellness education benefits: |
Written health education materials including Newsletters |
Additional Smoking Cessation |
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. |
** Cost ** |
Premium and Other Important Information |
Package: 1 - Wisconsin Rider: |
$29 monthly premium in addition to your $___ monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Skilled Nursing Facility (SNF)
- Home Health Services
- Other 1
- Eye Wear
|
** Extra Benefits ** |
Vision Services |
$0 copay for |
glasses |
contacts |
** Important Information ** |
Premium and Other Important Information |
Package: 1 - Wisconsin Rider: |
$29 monthly premium in addition to your $___ monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Skilled Nursing Facility (SNF)
- Home Health Services
- Other 1
- Eye Wear
|
** Additional Benefits ** |
Vision Services |
$0 copay for |
glasses |
contacts |