** Cost ** |
Premium and Other Important Information |
$0.00 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 a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B 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. |
$3 400 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. |
** Extra Benefits ** |
Prescription Drugs |
Most drugs not covered. |
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
This plan does not offer prescription drug coverage. |
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
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. |
$0 to $40 copay for up to 1 routine eye exam(s) every year |
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 |
$0.00 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 a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B 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. |
$3 400 out-of-pocket limit. |
This limit includes only Medicare-covered services. |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
** 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 - 6: $265 copay per day |
Days 7 - 90: $0 copay per day |
$0 copay for additional hospital days |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Inpatient Mental Health Care |
You get up to 190 days in a Psychiatric Hospital in a lifetime. |
For Medicare-covered hospital stays: |
Days 1 - 15: $140 copay per day |
Days 16 - 90: $0 copay per day |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
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 - 10: $0 copay per day |
Days 11 - 100: $100 copay per day |
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. |
$40 copay for each in-area network urgent care Medicare-covered visit. |
$40 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
$40 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. |
Podiatry Services |
$40 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
$40 copay for each Medicare-covered individual or group therapy visit. |
Outpatient Substance Abuse Care |
$40 copay for Medicare-covered individual or group visits. |
Outpatient Hospital Services |
Authorization rules may apply. |
$0 to $250 copay for each Medicare-covered ambulatory surgical center visit. |
$0 to $250 copay 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. |
$0 copay for Medicare-covered Cardiac Rehab services. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
Prosthetic Devices |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies |
Authorization rules may apply. |
$0 copay for Diabetes self-monitoring training. |
$0 copay for Nutrition Therapy for Diabetes. |
20% of the cost 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. |
Pap Smears and Pelvic Exams |
$0 copay for Medicare-covered pap smears and pelvic exams. |
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 |
Most drugs not covered. |
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
This plan does not offer prescription drug coverage. |
Dental Services |
$0 copay for Medicare-covered dental benefits. |
In general preventive dental benefits (such as cleaning) not covered. |
Hearing Services |
Hearing aids not covered. |
$40 copay for Medicare-covered diagnostic hearing exams |
$40 copay for up to 1 routine hearing test(s) every year |
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. |
$0 to $40 copay for up to 1 routine eye exam(s) every year |
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 |
Nutritional Training |
Nutritional benefit |
Additional Smoking Cessation |
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 |
Authorization rules may apply. |
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
|
For hospital stays: |
Days 1 - 90: 25% of the cost per day |
For Inpatient Psychiatric Hospital stays: |
25% of the cost per day for day(s) 1 - 90 |
For each SNF stay: |
Days 1 - 100: $100 copay per SNF day |
20% of the cost for - Home Health Services
- Outpatient Diag Procs/Tests/Lab Services
- Diagnostic Radiological Services
- Therapeutic Radiological Services
- Outpatient X-Rays
- Outpatient Hospital Services
- Ambulatory Surgical Center (ASC) Services
- Blood
|
$15 copay for - Primary Care Physician Services
- Immunizations
- Routine Physical Exams
- Pap Smears and Pelvic Exams
- Prostate Screening
- Colorectal Screening
- Bone Mass Measurement
- Mammography Screening
- Diabetes Monitoring
- Nutrition Therapy for Diabetes and Renal Disease
|
$55 copay for - Comprehensive Outpatient Rehabilitation Facility (CORF)
- Partial Hospitalization
- Chiropractic Services
- Occupational Therapy Services
- Physician Specialist Services
- Podiatry Services
- Other Health Care Professional
- Physical Therapy and Speech/Language Pathology Services
- Cardiac Rehabilitation Services
- Comprehensive Dental
- Eye Exams
- Hearing Exams
|
30% of the cost for - DME
- Prosthetics/Medical Supplies
- Diabetes Monitoring Supplies
|
$250 copay for |
$40 copay for - Mental Health Specialty Services
- Psychiatric Services
- Outpatient Substance Abuse
|