** 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. |
$6 800 out-of-pocket limit. |
In-Network: This limit includes only Medicare-covered services. |
Out-Of-Network: This limit includes only Medicare-covered 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 |
Most drugs not covered. |
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
30% of the cost for Part B drugs out-of-network. |
This plan does not offer prescription drug coverage. |
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 $35 copay for exams to diagnose and treat diseases and conditions of the eye. |
$35 copay for up to 1 routine eye exam(s) every year |
$40 copay for eye exams. |
30% of the cost for eye wear. |
Dental Services |
In general preventive dental benefits (such as cleaning) not covered. |
$35 copay for Medicare-covered dental benefits. |
$40 copay 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 covers all Medicare-covered preventive services with zero cost sharing. |
$3 400 out-of-pocket limit. |
This limit includes only Medicare-covered services. |
$6 800 out-of-pocket limit. |
In-Network: This limit includes only Medicare-covered services. |
Out-Of-Network: This limit includes only Medicare-covered 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 - 7: $250 copay per day |
Days 8 - 90: $0 copay per day |
$0 copay for each additional hospital day. |
For hospital stays: |
Days 1 - 24: $295 copay per day |
Days 25 and beyond: $0 copay per 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 - 7: $250 copay per day |
Days 8 - 90: $0 copay per day |
For hospital stays: |
Days 1 - 24: $295 copay per day |
Days 25 - 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 - 52: $75 copay per day |
Days 53 - 100: $0 copay per day |
For each SNF stay: |
Days 1 - 40: $150 copay per SNF day |
Days 41 - 100: $0 copay per SNF day |
Home Health Care |
$0 copay for each Medicare-covered home health visit. |
30% for home health visits. |
Hospice |
You must get care from a Medicare-certified hospice. |
** Outpatient Care ** |
Doctor Office Visits |
$15 copay for each primary care doctor visit for Medicare-covered benefits. |
$30 copay for each in-area network urgent care Medicare-covered visit. |
$35 copay for each specialist visit for Medicare-covered benefits. |
$20 copay for each primary care doctor visit. |
$40 copay for each specialist visit. |
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. |
50% of the cost for chiropractic benefits. |
Podiatry Services |
$35 copay for each Medicare-covered visit. |
$35 copay for up to 6 routine visit(s) every year |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
$40 copay for podiatry benefits. |
Outpatient Mental Health Care |
$40 copay for each Medicare-covered individual therapy visit. |
$30 copay for each Medicare-covered group therapy visit. |
$35 to $45 copay for Mental Health benefits. |
$35 to $45 copay for Mental Health benefits with a psychiatrist. |
Outpatient Substance Abuse Care |
$40 copay for Medicare-covered individual visits. |
$30 copay for Medicare-covered group visits. |
$35 to $45 copay for outpatient substance abuse benefits. |
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. |
30% of the cost for ambulatory surgical center benefits. |
30% of the cost 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 24-hour(s) for the same condition you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
$35 copay for Medicare-covered Occupational Therapy visits. |
$35 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$35 copay for Medicare-covered Cardiac Rehab services. |
$40 copay for Occupational Therapy benefits. |
$40 copay for Physical and/or Speech and Language Therapy visits. |
$40 copay for Cardiac Rehab services. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
20% of the cost for Medicare-covered items. |
30% of the cost for durable medical equipment. |
Prosthetic Devices |
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. |
30% of the cost for Diabetes self-monitoring training. |
30% 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. |
30% of the cost 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. |
30% of the cost 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 up to 1 additional pap smear(s) and pelvic exam(s) every year |
30% of the cost for pap smears and pelvic exams. |
Prostate Cancer Screening Exams |
$0 copay for Medicare-covered prostate cancer screening. |
30% of the cost 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. |
30% 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. |
30% of the cost for Part B drugs out-of-network. |
This plan does not offer prescription drug coverage. |
Dental Services |
In general preventive dental benefits (such as cleaning) not covered. |
$35 copay for Medicare-covered dental benefits. |
$40 copay for comprehensive dental benefits. |
Hearing Services |
$35 copay for Medicare-covered diagnostic hearing exams |
$35 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. |
$40 copay for hearing exams. |
$0 copay for hearing aids. |
Vision Services |
$0 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 to $35 copay for exams to diagnose and treat diseases and conditions of the eye. |
$35 copay for up to 1 routine eye exam(s) every year |
$40 copay for eye exams. |
30% of the cost for eye wear. |
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 |
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. |
$0 copay for Health and Wellness services. |
Transportation |
This plan does not cover routine transportation. |
Acupuncture |
This plan does not cover Acupuncture. |
** 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 |
$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) |
$0 copay for preventive dental services. |
0% to 50% of the cost for comprehensive dental services. |
$1 000 plan coverage limit for dental benefits every year. This limit applies to both in-network and out-of-network benefits. |
Contact the plan for availability of additional in-network and out-of-network comprehensive dental benefits. |
** 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 |
$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) |
$0 copay for preventive dental services. |
0% to 50% of the cost for comprehensive dental services. |
$1 000 plan coverage limit for dental benefits every year. This limit applies to both in-network and out-of-network benefits. |
Contact the plan for availability of additional in-network and out-of-network comprehensive dental benefits. |
** Cost ** |
Premium and Other Important Information |
Package: 2 - Fitness Rider: |
$13 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Health Education/Wellness
|
** Important Information ** |
Package: 2 - Fitness Rider: |
$13 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Health Education/Wellness
|