** 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 does not cover all Medicare-covered preventive services with zero cost sharing. |
$6 700 out-of-pocket limit. |
All plan services included. |
$2 500 out-of-pocket limit. |
There is no limit on cost sharing for the following services: Medicare Services: - Skilled Nursing Facility (SNF)
- Comprehensive Outpatient Rehabilitation Facility (CORF)
- Urgently Needed Care
- 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
- Outpatient Diag/Therapeutic Rad Services
- Outpatient Hospital Services
- Ambulatory Surgical Center (ASC) Services
- Outpatient Substance Abuse
- Cardiac Rehabilitation Services
- Ambulance Services
- DME
- Prost
|
This limit includes only Medicare-covered services. |
$10 000 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 go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
** Extra Benefits ** |
Prescription Drugs |
Most drugs not covered. |
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
50% of the cost for Part B drugs out-of-network. |
This plan does not offer prescription drug coverage. |
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
25% of the cost for routine exams. |
Vision Services |
$40 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 copay for exams to diagnose and treat diseases and conditions of the eye. |
$20 copay for up to 1 routine eye exam(s) every year |
$40 copay for up to 1 pair(s) of glasses every year |
$40 copay for up to 1 pair(s) of contacts every year |
25% to 50% of the cost for eye exams. |
50% of the cost for eye wear. |
Dental Services |
$0 copay for the following preventive dental benefits: |
up to 1 oral exam(s) every year |
up to 1 cleaning(s) every year |
$20 copay for Medicare-covered dental benefits. |
50% of the cost for preventive dental benefits. |
25% of the cost for comprehensive dental benefits. |
** 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 does not cover all Medicare-covered preventive services with zero cost sharing. |
$6 700 out-of-pocket limit. |
All plan services included. |
$2 500 out-of-pocket limit. |
There is no limit on cost sharing for the following services: Medicare Services: - Skilled Nursing Facility (SNF)
- Comprehensive Outpatient Rehabilitation Facility (CORF)
- Urgently Needed Care
- 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
- Outpatient Diag/Therapeutic Rad Services
- Outpatient Hospital Services
- Ambulatory Surgical Center (ASC) Services
- Outpatient Substance Abuse
- Cardiac Rehabilitation Services
- Ambulance Services
- DME
- Prost
|
This limit includes only Medicare-covered services. |
$10 000 out-of-pocket limit. |
All plan services included. |
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. |
** 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 - 7: $100 copay per day |
Days 8 - 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. |
25% of the cost for each hospital stay. |
Inpatient Mental Health Care |
You get up to 190 days in a Psychiatric Hospital in a lifetime. |
For Medicare-covered hospital stays: |
Days 1 - 7: $100 copay per day |
Days 8 - 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. |
25% of the cost for each hospital stay. |
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: $25 copay per day |
Days 21 - 100: $50 copay per day |
25% of the cost for each SNF stay. |
Home Health Care |
Authorization rules may apply. |
$0 copay for Medicare-covered home health visits. |
$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. |
25% for each primary care doctor visit. |
25% for each specialist visit. |
Chiropractic Services |
Authorization rules may apply. |
$20 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. |
$40 copay for chiropractic benefits. |
Podiatry Services |
Authorization rules may apply. |
$20 copay for each Medicare-covered visit. |
$20 copay for up to 4 routine visit(s) every year |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
$40 copay for podiatry benefits. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$20 copay for each Medicare-covered individual or group therapy visit. |
25% of the cost for Mental Health benefits. |
25% of the cost for Mental Health benefits with a psychiatrist. |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$20 copay for Medicare-covered individual or group visits. |
25% of the cost for outpatient substance abuse benefits. |
Outpatient Hospital Services |
$100 copay for each Medicare-covered ambulatory surgical center visit. |
$100 copay for each Medicare-covered outpatient hospital facility visit. |
25% of the cost for ambulatory surgical center benefits. |
25% of the cost for outpatient hospital facility benefits. |
Emergency Care |
$0 to $50 copay for Medicare-covered emergency room visits |
Worldwide coverage. |
If you are admitted to the hospital within 1-day for the same condition you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
$20 copay for Medicare-covered Occupational Therapy visits. |
$20 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$20 copay for Medicare-covered Cardiac Rehab services. |
50% of the cost for Occupational Therapy benefits. |
50% of the cost for Physical and/or Speech and Language Therapy visits. |
50% of the cost for Cardiac Rehab services. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
30% of the cost for durable medical equipment. |
Prosthetic Devices |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
30% 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. |
Separate Office Visit cost sharing of $10 to $20 may apply. |
25% of the cost for Diabetes self-monitoring training. |
25% of the cost for Nutrition Therapy for Diabetes. |
30% of the cost for Diabetes supplies. |
** Preventive Services ** |
Bone Mass Measurement |
$0 copay for Medicare-covered bone mass measurement |
Separate Office Visit cost sharing of $10 to $20 may apply. |
25% of the cost for Medicare-covered bone mass measurement. |
Colorectal Screening Exams |
$0 copay for Medicare-covered colorectal screenings. |
Separate Office Visit cost sharing of $10 to $20 may apply. |
25% of the cost for colorectal screenings. |
Immunizations |
$0 copay for Flu and Pneumonia vaccines. |
$0 copay for Hepatitis B vaccine. |
No referral needed for Flu and pneumonia vaccines. |
$0 copay for 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 |
Separate Office Visit cost sharing of $10 to $20 may apply. |
25% of the cost for pap smears and pelvic exams. |
Prostate Cancer Screening Exams |
$0 copay for - Medicare-covered prostate cancer screening
|
Separate Office Visit cost sharing of $10 to $20 may apply. |
25% of the cost for prostate cancer screening. |
** Additional Benefits ** |
Dialysis |
$0 copay for renal dialysis |
$0 copay for Nutrition Therapy for End-Stage Renal Disease |
$0 copay for renal dialysis. |
25% of the cost 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. |
50% of the cost for Part B drugs out-of-network. |
This plan does not offer prescription drug coverage. |
Dental Services |
$0 copay for the following preventive dental benefits: |
up to 1 oral exam(s) every year |
up to 1 cleaning(s) every year |
$20 copay for Medicare-covered dental benefits. |
50% of the cost for preventive dental benefits. |
25% of the cost for comprehensive dental benefits. |
Hearing Services |
In general routine hearing exams and hearing aids not covered. |
$20 copay for Medicare-covered diagnostic hearing exams |
25% of the cost for hearing exams. |
Vision Services |
$40 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 copay for exams to diagnose and treat diseases and conditions of the eye. |
$20 copay for up to 1 routine eye exam(s) every year |
$40 copay for up to 1 pair(s) of glasses every year |
$40 copay for up to 1 pair(s) of contacts every year |
25% to 50% of the cost for eye exams. |
50% of the cost for eye wear. |
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
25% of the cost for routine exams. |
Health/Wellness Education |
The plan covers the following health/wellness education benefits: |
Written health education materials including Newsletters |
Nutritional Training |
Nursing Hotline |
Other Wellness 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. |