** Cost ** |
Premium and Other Important Information |
$75.00 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. |
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. |
No referral required for network doctors specialists and hospitals. |
** Extra Benefits ** |
Prescription Drugs |
Most drugs not covered. |
20% of the cost for Part B-covered chemotherapy drugs and other 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. |
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. |
Separate Office Visit cost sharing of $15 may apply. |
Vision Services |
20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 to $25 copay for exams to diagnose and treat diseases and conditions of the eye. |
$25 copay for up to 1 routine eye exam(s) every year |
0% of the cost for up to 1 pair(s) of contacts every two years |
0% of the cost for up to 1 pair(s) of lenses every two years |
0% of the cost for up to 1 frame(s) every two years |
$100 plan coverage limit for contact lenses every two years. |
$75 plan coverage limit for eye glass frames every two years. |
Dental Services |
Authorization rules may apply. |
$0 copay for the following preventive dental benefits: |
up to 2 oral exam(s) every year |
up to 2 cleaning(s) every year |
$25 to $125 copay for Medicare-covered dental benefits. |
$100 plan coverage limit for preventive dental benefits every year. |
** Important Information ** |
Premium and Other Important Information |
$75.00 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. |
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. |
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 Medicare-covered hospital stays: |
Days 1 - 5: $150 copay per day |
Days 6 - 90: $0 copay per day |
$0 copay for each additional hospital day. |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Inpatient Mental Health Care |
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. |
For Medicare-covered hospital stays: |
Days 1 - 5: $150 copay per day |
Days 6 - 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. |
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 - 15: $0 copay per day |
Days 16 - 100: $90 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. |
Authorization rules may apply. |
$15 copay for each primary care doctor visit for Medicare-covered benefits. |
$25 copay for each in-area network urgent care Medicare-covered visit. |
$25 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
Authorization rules may apply. |
$25 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. |
$25 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$25 copay for each Medicare-covered individual or group therapy visit. |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$25 copay for Medicare-covered individual or group visits. |
Outpatient Hospital Services |
Authorization rules may apply. |
$125 copay for each Medicare-covered ambulatory surgical center visit. |
$125 copay for each Medicare-covered outpatient hospital facility visit. |
Emergency Care |
$50 copay for Medicare-covered emergency room visits. |
Not covered outside the U.S. except under limited circumstances. Contact the plan for more details. |
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 |
$25 copay for Medicare-covered Occupational Therapy visits. |
$25 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$10 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. |
20% of the cost for Diabetes supplies. |
Separate Office Visit cost sharing of $15 to $25 may apply. |
** Preventive Services ** |
Bone Mass Measurement |
$0 copay for Medicare-covered bone mass measurement |
Separate Office Visit cost sharing of $15 to $25 may apply. |
Colorectal Screening Exams |
$0 copay for Medicare-covered colorectal screenings. |
Separate Office Visit cost sharing of $15 to $25 may apply. |
$0 to $125 copay for additional screenings. |
No limit on the number of covered colorectal screenings. |
Immunizations |
$0 copay for Flu and Pneumonia vaccines. |
$0 copay for Hepatitis B vaccine. |
No referral needed for Flu and pneumonia vaccines. |
Separate Office Visit cost sharing of $15 to $25 may apply. |
No referral needed for other immunizations. |
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 $15 to $25 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 $15 to $25 may apply. |
No limit on the number of covered prostate cancer screenings. |
** Additional Benefits ** |
Dialysis |
5% of the cost for renal dialysis |
$0 copay 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. |
This plan does not offer prescription drug coverage. |
Dental Services |
Authorization rules may apply. |
$0 copay for the following preventive dental benefits: |
up to 2 oral exam(s) every year |
up to 2 cleaning(s) every year |
$25 to $125 copay for Medicare-covered dental benefits. |
$100 plan coverage limit for preventive dental benefits every year. |
Hearing Services |
Authorization rules may apply. |
Hearing aids not covered. |
$25 copay for Medicare-covered diagnostic hearing exams |
$25 copay for up to 1 routine hearing test(s) every year |
Vision Services |
20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 to $25 copay for exams to diagnose and treat diseases and conditions of the eye. |
$25 copay for up to 1 routine eye exam(s) every year |
0% of the cost for up to 1 pair(s) of contacts every two years |
0% of the cost for up to 1 pair(s) of lenses every two years |
0% of the cost for up to 1 frame(s) every two years |
$100 plan coverage limit for contact lenses every two years. |
$75 plan coverage limit for eye glass frames every two years. |
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. |
Separate Office Visit cost sharing of $15 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 |
Additional Smoking Cessation |
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. |
Transportation |
This plan does not cover routine transportation. |
Acupuncture |
This plan does not cover Acupuncture. |