** Cost ** |
Premium and Other Important Information |
$55.00 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. |
$3 400 out-of-pocket limit. |
There is no limit on cost sharing for the following services: Supplemental Services: - Preventive Dental
- Eye Wear
|
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network hospitals and specialists (for certain benefits). |
** Extra Benefits ** |
Prescription Drugs |
Most drugs not covered. |
$0 copay for Part B-covered drugs. |
This plan does not offer prescription drug coverage. |
Physical Exams |
$0 copay for routine exams. |
No plan coverage limit on the number of covered exams. |
Separate Office Visit cost sharing of $20 may apply. |
Vision Services |
$0 copay for diagnosis and treatment for diseases and conditions of the eye |
and routine eye exams. |
$0 copay for - one pair of eyeglasses or contact lenses after cataract surgery
|
up to 1 pair(s) of contacts |
up to 1 pair(s) of lenses |
up to 1 frame(s) |
Separate Office Visit cost sharing of $20 to $35 may apply. |
$80 plan coverage limit for contact lenses. |
$80 plan coverage limit for eye glass frames. |
Dental Services |
Authorization rules may apply. |
$0 copay for Medicare-covered dental benefits. |
In general preventive dental benefits (such as cleaning) not covered. |
Separate Office Visit cost sharing of $20 to $35 may apply. |
** Important Information ** |
Premium and Other Important Information |
$55.00 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. |
$3 400 out-of-pocket limit. |
There is no limit on cost sharing for the following services: Supplemental Services: - Preventive Dental
- Eye Wear
|
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network hospitals and specialists (for certain benefits). |
** Inpatient Care ** |
Inpatient Hospital Care (Acute) |
No limit to the number of days covered by the plan each benefit period. |
$350 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. |
Inpatient Mental Health Care |
You get up to 190 days in a Psychiatric Hospital in a lifetime. |
$350 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. |
Skilled Nursing Facility (SNF) |
Authorization rules may apply. |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
You will not be charged additional cost sharing for professional 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. |
Authorization rules may apply. |
$20 copay for each primary care doctor visit for Medicare-covered benefits. |
$35 copay for each in-area network urgent care Medicare-covered visit. |
$35 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
Authorization rules may apply. |
$35 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 |
Authorization rules may apply. |
$35 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
$35 copay for each Medicare-covered individual or group therapy visit. |
Outpatient Substance Abuse Care |
$35 copay for Medicare-covered individual or group visits. |
Outpatient Hospital Services |
Authorization rules may apply. |
$0 to $50 copay for each Medicare-covered ambulatory surgical center visit. |
$0 to $50 copay for each Medicare-covered outpatient hospital facility visit. |
Emergency Care |
$50 copay for Medicare-covered emergency room visits. |
Worldwide coverage. |
If you are immediately admitted to the hospital you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits. |
$15 copay for Medicare-covered Occupational Therapy visits. |
$15 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$15 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. |
$0 copay for Diabetes supplies. |
Separate Office Visit cost sharing of $20 to $35 may apply. |
** Preventive Services ** |
Bone Mass Measurement |
Authorization rules may apply. |
$0 copay for Medicare-covered bone mass measurement |
Separate Office Visit cost sharing of $20 to $35 may apply. |
Colorectal Screening Exams |
$0 copay for - Medicare-covered colorectal screenings
|
additional screenings |
Separate Office Visit cost sharing of $20 to $35 may apply. |
No limit on the number of covered colorectal screenings. |
Immunizations |
Authorization rules may apply. |
$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 |
additional pap smears and pelvic exams |
Separate Office Visit cost sharing of $20 to $35 may apply. |
No limit on the number of covered pap smears and pelvic exams. |
Prostate Cancer Screening Exams |
$0 copay for - Medicare-covered prostate cancer screening
|
additional screening |
Separate Office Visit cost sharing of $20 to $35 may apply. |
No limit on the number of covered prostate cancer screenings. |
** Additional Benefits ** |
Dialysis |
Authorization rules may apply. |
$0 to $25 copay for renal dialysis |
$0 copay for Nutrition Therapy for End-Stage Renal Disease |
Prescription Drugs |
Most drugs not covered. |
$0 copay for Part B-covered drugs. |
This plan does not offer prescription drug coverage. |
Dental Services |
Authorization rules may apply. |
$0 copay for Medicare-covered dental benefits. |
In general preventive dental benefits (such as cleaning) not covered. |
Separate Office Visit cost sharing of $20 to $35 may apply. |
Hearing Services |
Hearing aids not covered. |
$0 copay for Medicare-covered diagnostic hearing exams |
routine hearing tests |
Vision Services |
$0 copay for diagnosis and treatment for diseases and conditions of the eye |
and routine eye exams. |
$0 copay for - one pair of eyeglasses or contact lenses after cataract surgery
|
up to 1 pair(s) of contacts |
up to 1 pair(s) of lenses |
up to 1 frame(s) |
Separate Office Visit cost sharing of $20 to $35 may apply. |
$80 plan coverage limit for contact lenses. |
$80 plan coverage limit for eye glass frames. |
Physical Exams |
$0 copay for routine exams. |
No plan coverage limit on the number of covered exams. |
Separate Office Visit cost sharing of $20 may apply. |
Health/Wellness Education |
Authorization rules may apply. |
The plan covers the following health/wellness education benefits: |
Written health education materials including Newsletters |
Nutritional Training |
Nutritional benefit |
Additional Smoking Cessation |
Health Club Membership/Fitness Classes |
$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 - Delta Dental Option 1: |
$23.40 monthly premium in addition to your $55 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Preventive Dental
- Comprehensive Dental
|
$800 plan coverage limit every year for these benefits. |
** Extra Benefits ** |
Dental Services |
Plan offers additional comprehensive dental benefits. |
50% of the cost for up to 2 cleaning(s) every year |
50% of the cost for up to 2 fluoride treatment(s) every year |
50% of the cost for oral exams |
50% of the cost for dental x-rays |
** Important Information ** |
Premium and Other Important Information |
Package: 1 - Delta Dental Option 1: |
$23.40 monthly premium in addition to your $55 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Preventive Dental
- Comprehensive Dental
|
$800 plan coverage limit every year for these benefits. |
** Additional Benefits ** |
Dental Services |
Plan offers additional comprehensive dental benefits. |
50% of the cost for up to 2 cleaning(s) every year |
50% of the cost for up to 2 fluoride treatment(s) every year |
50% of the cost for oral exams |
50% of the cost for dental x-rays |
** Cost ** |
Premium and Other Important Information |
Package: 2 - Delta Dental Option 2: |
$44.90 monthly premium in addition to your $55 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Preventive Dental
- Comprehensive Dental
|
$1 500 plan coverage limit every year for these benefits. |
** Extra Benefits ** |
Dental Services |
Plan offers additional comprehensive dental benefits. |
0% of the cost for up to 2 cleaning(s) every year |
0% of the cost for up to 2 fluoride treatment(s) every year |
0% of the cost for oral exams |
30% of the cost for dental x-rays |
** Important Information ** |
Premium and Other Important Information |
Package: 2 - Delta Dental Option 2: |
$44.90 monthly premium in addition to your $55 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Preventive Dental
- Comprehensive Dental
|
$1 500 plan coverage limit every year for these benefits. |
** Additional Benefits ** |
Dental Services |
Plan offers additional comprehensive dental benefits. |
0% of the cost for up to 2 cleaning(s) every year |
0% of the cost for up to 2 fluoride treatment(s) every year |
0% of the cost for oral exams |
30% of the cost for dental x-rays |