** 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. |
$3 300 out-of-pocket limit. |
This limit includes only Medicare-covered services. |
$250 yearly deductible. Contact the plan for services that apply. |
$3 300 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. |
25% 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. |
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. |
$30 copay for routine exams. |
Vision Services |
$0 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. |
$0 copay for up to 1 routine eye exam(s) every year |
$0 copay for up to 1 pair(s) of glasses every two years |
$0 copay for up to 1 pair(s) of contacts every two years |
$100 plan coverage limit for eye glasses (lenses and frames) every two years. |
$80 plan coverage limit for contact lenses every two years. |
$0 copay for eye exams. |
$0 copay for eye wear. |
Dental Services |
$0 copay for Medicare-covered dental benefits. |
$20 copay for an office visit that includes: |
up to 1 oral exam(s) every year |
up to 1 cleaning(s) every year |
20% of the cost for preventive dental benefits. |
$0 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. |
$3 300 out-of-pocket limit. |
This limit includes only Medicare-covered services. |
$250 yearly deductible. Contact the plan for services that apply. |
$3 300 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. |
$750 copay for each Medicare-covered hospital stay |
$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. |
15% of the cost for each hospital stay. |
Inpatient Mental Health Care |
You get up to 190 days in a Psychiatric Hospital in a lifetime. |
$750 copay for each Medicare-covered hospital stay. |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
15% 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: $0 copay per day |
Days 21 - 100: $100 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. |
30% 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. |
$15 copay for each primary care doctor visit for Medicare-covered benefits. |
$35 copay for each in-area network urgent care Medicare-covered visit. |
$30 copay for each specialist visit for Medicare-covered benefits. |
$30 copay for each primary care doctor visit. |
$45 copay for each specialist visit. |
Chiropractic Services |
Authorization rules may apply. |
$10 copay for each Medicare-covered visit. |
$30 copay for up to 20 routine visit(s) every year |
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. |
$45 copay for chiropractic benefits. |
Podiatry Services |
$30 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
$45 copay for podiatry benefits. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$40 copay for each Medicare-covered individual or group therapy visit. |
30% of the cost for Mental Health benefits. |
30% of the cost for Mental Health benefits with a psychiatrist. |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$40 copay for Medicare-covered individual or group visits. |
30% of the cost for outpatient substance abuse benefits. |
Outpatient Hospital Services |
Authorization rules may apply. |
$100 copay for each Medicare-covered ambulatory surgical center visit. |
$30 to $200 copay 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 72-hour(s) for the same condition you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
$30 to $50 copay for Medicare-covered Occupational Therapy visits. |
$30 to $50 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$30 copay for Medicare-covered Cardiac Rehab services. |
30% of the cost for Occupational Therapy benefits. |
30% of the cost for Physical and/or Speech and Language Therapy visits. |
30% 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. |
25% 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. |
20% of the cost 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. |
30% 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 |
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 |
10% of the cost for renal dialysis |
$0 copay for Nutrition Therapy for End-Stage Renal Disease. |
10% 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. |
25% of the cost for Part B drugs out-of-network. |
This plan does not offer prescription drug coverage. |
Dental Services |
$0 copay for Medicare-covered dental benefits. |
$20 copay for an office visit that includes: |
up to 1 oral exam(s) every year |
up to 1 cleaning(s) every year |
20% of the cost for preventive dental benefits. |
$0 copay for comprehensive dental benefits. |
Hearing Services |
$30 copay for Medicare-covered diagnostic hearing exams |
$0 copay for up to 1 routine hearing test(s) every year |
$0 copay per hearing aid |
$100 plan coverage limit for hearing aids every two years. |
30% of the cost for hearing exams. |
$0 copay for hearing aids. |
Vision Services |
$0 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. |
$0 copay for up to 1 routine eye exam(s) every year |
$0 copay for up to 1 pair(s) of glasses every two years |
$0 copay for up to 1 pair(s) of contacts every two years |
$100 plan coverage limit for eye glasses (lenses and frames) every two years. |
$80 plan coverage limit for contact lenses every two years. |
$0 copay for eye exams. |
$0 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. |
$30 copay for routine exams. |
Health/Wellness Education |
The plan covers the following health/wellness education benefits: |
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. |
$0 copay for Health and Wellness services. |
Transportation |
This plan does not cover routine transportation. |
Acupuncture |
$30 copay per visit up to 20 visit(s) every year. |
$45 copay for acupuncture visits. |