** Cost ** |
Premium and Other Important Information |
$49.50 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. |
$6 700 out-of-pocket limit. |
There is no limit on cost sharing for the following services: Supplemental Services: - Preventive Dental
- Comprehensive Dental
- Eye Wear
- Hearing Exams
- Hearing Aids
|
$900 yearly deductible. Contact the plan for services that apply. |
$6 200 out-of-pocket limit. |
There is no limit on cost sharing for the following services: Supplemental Services: - Preventive Dental
- Comprehensive Dental
- Hearing Exams
|
** 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. |
$0 copay for 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. |
Separate Office Visit cost sharing of $0 to $35 may apply. |
Vision Services |
$0 copay for - one pair of eyeglasses or contact lenses after cataract surgery
|
glasses |
contacts |
lenses |
frames |
$0 to $35 copay for exams to diagnose and treat diseases and conditions of the eye. |
$15 to $35 copay for up to 1 routine eye exam(s) every year |
$100 plan coverage limit for eye wear every two years. |
Dental Services |
$0 copay for Medicare-covered dental benefits. |
$0 copay for the following preventive dental benefits: |
up to 1 oral exam(s) every six months |
up to 1 cleaning(s) every six months |
up to 1 dental x-ray(s) every three years |
Plan offers additional comprehensive dental benefits. |
** Important Information ** |
Premium and Other Important Information |
$49.50 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. |
$6 700 out-of-pocket limit. |
There is no limit on cost sharing for the following services: Supplemental Services: - Preventive Dental
- Comprehensive Dental
- Eye Wear
- Hearing Exams
- Hearing Aids
|
$900 yearly deductible. Contact the plan for services that apply. |
$6 200 out-of-pocket limit. |
There is no limit on cost sharing for the following services: Supplemental Services: - Preventive Dental
- Comprehensive Dental
- Hearing Exams
|
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 hospital stays: |
Days 1 - 10: $75 copay per day |
Days 11 - 90: $0 copay per day |
$0 copay for each additional hospital day. |
$750 out-of-pocket limit every stay. |
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 - 10: $75 copay per day |
Days 11 - 90: $0 copay per day |
Plan covers 60 lifetime reserve days. Cost per lifetime reserve day: |
Days 1 - 60: $0 copay per day |
$750 out-of-pocket limit every 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. |
For SNF stays: |
Days 1 - 5: $0 copay per day |
Days 6 - 22: $50 copay per day |
Days 23 - 100: $100 copay per day |
Home Health Care |
Authorization rules may apply. |
$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. |
$15 to $35 copay for each primary care doctor visit for Medicare-covered benefits. |
$0 to $35 copay for each in-area network urgent care Medicare-covered visit. |
$35 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
$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 |
$15 to $35 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$35 copay for each Medicare-covered individual or group therapy visit. |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$35 copay for Medicare-covered individual or group visits. |
Outpatient Hospital Services |
Authorization rules may apply. |
$75 copay for each Medicare-covered ambulatory surgical center visit. |
$35 to $125 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 |
Authorization rules may apply. |
$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. |
** 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 $0 to $35 may apply. |
** Preventive Services ** |
Bone Mass Measurement |
$0 copay for Medicare-covered bone mass measurement |
Separate Office Visit cost sharing of $0 to $35 may apply. |
Colorectal Screening Exams |
$0 copay for Medicare-covered colorectal screenings. |
Separate Office Visit cost sharing of $0 to $35 may apply. |
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 |
up to 1 additional pap smear(s) and pelvic exam(s) every year |
Separate Office Visit cost sharing of $0 to $35 may apply. |
Prostate Cancer Screening Exams |
$0 copay for - Medicare-covered prostate cancer screening
|
Separate Office Visit cost sharing of $0 to $35 may apply. |
** Additional Benefits ** |
Dialysis |
$0 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 |
$0 copay for Medicare-covered dental benefits. |
$0 copay for the following preventive dental benefits: |
up to 1 oral exam(s) every six months |
up to 1 cleaning(s) every six months |
up to 1 dental x-ray(s) every three years |
Plan offers additional comprehensive dental benefits. |
Hearing Services |
$0 copay for |
per inner-ear hearing aid(s) |
per outer-ear hearing aid(s) |
per over-the-ear hearing aid(s) |
$15 to $35 copay for Medicare-covered diagnostic hearing exams |
$15 to $35 copay for up to 1 routine hearing test(s) every year |
$0 copay for up to 1 hearing aid fitting evaluation(s) every three years |
$1 250 plan coverage limit for hearing aids every three years. |
Vision Services |
$0 copay for - one pair of eyeglasses or contact lenses after cataract surgery
|
glasses |
contacts |
lenses |
frames |
$0 to $35 copay for exams to diagnose and treat diseases and conditions of the eye. |
$15 to $35 copay for up to 1 routine eye exam(s) every year |
$100 plan coverage limit for eye wear every two years. |
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
Separate Office Visit cost sharing of $0 to $35 may apply. |
Health/Wellness Education |
The plan covers the following health/wellness education benefits: |
Written health education materials including Newsletters |
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. |
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
|
$900 yearly deductible for POS benefits |
$6 200 out-of-pocket limit every year for POS benefits |
35% of the cost per hospital stay. |
35% of the cost per Inpatient Psychiatric Hospital stay. |
35% of the cost for each SNF stay. |
35% of the cost for - 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
- Cardiac Rehabilitation Services
- DME
- Prosthetics/Medical Supplies
- Diabetes Monitoring Supplies
- Blood
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