** 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. |
$2 400 out-of-pocket limit. |
This limit includes only Medicare-covered services. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
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. |
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 |
$0 copay for contacts |
$0 copay for up to 1 pair(s) of lenses every two years |
$0 copay for up to 1 frame(s) every two years |
$105 plan coverage limit for contact lenses every two years. |
$70 plan coverage limit for eye glass frames every two years. |
Dental Services |
In general preventive dental benefits (such as cleaning) not covered. |
$35 copay for Medicare-covered 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. |
$2 400 out-of-pocket limit. |
This limit includes only Medicare-covered services. |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
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: $175 copay per day |
Days 8 - 90: $0 copay per day |
$0 copay for each additional hospital 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: $175 copay per day |
Days 8 - 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 - 34: $100 copay per day |
Days 35 - 100: $0 copay per day |
Home Health Care |
$0 copay for each Medicare-covered home health visit. |
Hospice |
You must get care from a Medicare-certified hospice. |
** Outpatient Care ** |
Doctor Office Visits |
$5 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. |
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. |
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. |
Outpatient Mental Health Care |
$40 copay for each Medicare-covered individual therapy visit. |
$30 copay for each Medicare-covered group therapy visit. |
Outpatient Substance Abuse Care |
$40 copay for Medicare-covered individual visits. |
$30 copay for Medicare-covered group visits. |
Outpatient Hospital Services |
$170 copay for each Medicare-covered ambulatory surgical center visit. |
$170 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 |
$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 |
20% of the cost for Medicare-covered items. |
Prosthetic Devices |
20% of the cost for Medicare-covered items. |
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. |
** Preventive Services ** |
Bone Mass Measurement |
$0 copay 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. |
Immunizations |
$0 copay for Flu and Pneumonia vaccines. |
No referral needed for Flu and pneumonia vaccines. |
$0 copay for Hepatitis B vaccine. |
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 |
Prostate Cancer Screening Exams |
$0 copay for Medicare-covered prostate cancer screening. |
** Additional Benefits ** |
Dialysis |
20% 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 |
In general preventive dental benefits (such as cleaning) not covered. |
$35 copay for Medicare-covered dental benefits. |
Hearing Services |
$35 copay for Medicare-covered diagnostic hearing exams |
$0 to $35 copay for up to 1 routine hearing test(s) every year |
$0 copay per hearing aid |
$1 000 plan coverage limit for hearing aids every two years. |
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 |
$0 copay for contacts |
$0 copay for up to 1 pair(s) of lenses every two years |
$0 copay for up to 1 frame(s) every two years |
$105 plan coverage limit for contact lenses every two years. |
$70 plan coverage limit for eye glass frames every two years. |
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. |
Transportation |
This plan does not cover routine transportation. |
Acupuncture |
This plan does not cover Acupuncture. |
Point of Service |
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
|
$6 500 out-of-pocket limit every year for POS benefits |
For hospital stays: |
Days 1 - 17: $400 copay per day |
Days 18 and beyond: $0 copay per day |
For Inpatient Psychiatric Hospital stays: |
Days 1 - 17: $400 copay per day |
Days 18 - 90: $0 copay per day |
For each SNF stay: |
Days 1 - 38: $175 copay per SNF day |
Days 39 - 100: $0 copay per SNF day |
$25 copay for - Primary Care Physician Services
- Other Health Care Professional
- Routine Physical Exams
|
$45 copay for - Comprehensive Outpatient Rehabilitation Facility (CORF)
- Occupational Therapy Services
- Physician Specialist Services
- Podiatry Services
- Physical Therapy and Speech/Language Pathology Services
- Cardiac Rehabilitation Services
- Comprehensive Dental
- Eye Exams
- Hearing Exams
|
30% of the cost for - Home Health Services
- Diagnostic Radiological Services
- Therapeutic Radiological Services
- Outpatient Hospital Services
- Ambulatory Surgical Center (ASC) Services
- DME
- Prosthetics/Medical Supplies
- Diabetes Monitoring Supplies
- Pap Smears and Pelvic Exams
- Prostate Screening
- Colorectal Screening
- Bone Mass Measurement
- Mammography Screening
- Diabetes Monitoring
- Nutrition Therapy for Diabetes and Renal Disease
- Eye Wear
|
$10 copay [or 30% of the cost] for - Outpatient Diag Procs/Tests/Lab Services
|
$21 copay for |
$75 copay for |
$200 copay for |
$35 to $45 copay for - Mental Health Specialty Services
- Psychiatric Services
- Outpatient Substance Abuse
|
$0 copay for - Blood
- Health Education/Wellness
- Immunizations
|
50% of the cost for |
** Cost ** |
Premium and Other Important Information |
Package: 1 - 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: 1 - 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
|