** Cost ** |
Premium and Other Important Information |
$59.00 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: - Health Education/Wellness
- Preventive Dental
- Comprehensive Dental
- Eye Wear
|
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
Referral required for network hospitals and specialists (for certain benefits). |
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. |
Plan covers you when you travel in the U.S. |
** Extra Benefits ** |
Prescription Drugs |
Most drugs not covered. |
$0 to $57 copay for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
This plan does not offer prescription drug coverage. |
Physical Exams |
$10 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 $10 may apply. |
Vision Services |
Authorization rules may apply. |
20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 to $10 copay for exams to diagnose and treat diseases and conditions of the eye. |
$10 copay for routine eye exams |
75% of the cost for glasses |
85% of the cost for contacts. |
Separate Office Visit cost sharing of $10 may apply. |
Dental Services |
Authorization rules may apply. |
$10 copay for Medicare-covered dental benefits. |
$30 copay for an office visit that includes: |
up to 1 oral exam(s) every six months |
up to 1 cleaning(s) every six months |
up to 1 fluoride treatment(s) every six months |
up to 1 dental x-ray(s) every six months |
Plan offers additional comprehensive dental benefits. |
** Important Information ** |
Premium and Other Important Information |
$59.00 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: - Health Education/Wellness
- Preventive Dental
- Comprehensive Dental
- Eye Wear
|
Doctor and Hospital Choice |
Referral required for network hospitals and specialists (for certain benefits). |
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. |
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. |
$250 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 |
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. |
$250 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. |
Skilled Nursing Facility (SNF) |
Authorization rules may apply. |
Plan covers up to 100 days each benefit period |
$250 copay for each Non-Medicare-covered SNF stay. |
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. |
$10 copay for each primary care doctor visit for Medicare-covered benefits. |
$10 copay for each in-area network urgent care Medicare-covered visit. |
$10 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
Authorization rules may apply. |
$10 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. |
$10 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$10 copay for each Medicare-covered individual or group therapy visit. |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$10 copay for Medicare-covered individual or group visits. |
Outpatient Hospital Services |
Authorization rules may apply. |
$100 copay for each Medicare-covered ambulatory surgical center visit. |
$100 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 48-hour(s) for the same condition you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
$10 copay for Medicare-covered Occupational Therapy visits. |
$10 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. |
$0 copay for Diabetes supplies. |
Separate Office Visit cost sharing of $10 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 $10 may apply. |
Colorectal Screening Exams |
Authorization rules may apply. |
$0 copay for Medicare-covered colorectal screenings. |
Separate Office Visit cost sharing of $10 may apply. |
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 |
Separate Office Visit cost sharing of $10 may apply. |
Prostate Cancer Screening Exams |
$0 copay for Medicare-covered prostate cancer screening. |
Separate Office Visit cost sharing of $10 may apply. |
** Additional Benefits ** |
Dialysis |
Cost plan members pay Fee-for-Service cost sharing for out-of-area dialysis. |
Authorization rules may apply. |
$0 copay for renal dialysis |
$0 copay for Nutrition Therapy for End-Stage Renal Disease. |
Prescription Drugs |
Most drugs not covered. |
$0 to $57 copay 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. |
$10 copay for Medicare-covered dental benefits. |
$30 copay for an office visit that includes: |
up to 1 oral exam(s) every six months |
up to 1 cleaning(s) every six months |
up to 1 fluoride treatment(s) every six months |
up to 1 dental x-ray(s) every six months |
Plan offers additional comprehensive dental benefits. |
Hearing Services |
Authorization rules may apply. |
In general routine hearing exams and hearing aids not covered. |
$10 copay for Medicare-covered diagnostic hearing exams |
Vision Services |
Authorization rules may apply. |
20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 to $10 copay for exams to diagnose and treat diseases and conditions of the eye. |
$10 copay for routine eye exams |
75% of the cost for glasses |
85% of the cost for contacts. |
Separate Office Visit cost sharing of $10 may apply. |
Physical Exams |
$10 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 $10 may apply. |
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. |