** Cost ** |
Premium and Other Important Information |
$155.5 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 higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D 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. |
$3 000 out-of-pocket limit. All plan services included. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
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 ** |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
This plan does not cover supplemental routine transportation. |
** Important Information ** |
Premium and Other Important Information |
$155.5 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 higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D 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. |
$3 000 out-of-pocket limit. All plan services included. |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
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 |
No limit to the number of days covered by the plan each hospital stay. |
$0 copay |
Inpatient Mental Health Care |
$0 copay |
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. |
Skilled Nursing Facility (SNF) |
Plan covers up to 100 days each benefit period |
$0 copay for SNF services |
Home Health Care |
$0 copay for Medicare-covered home health visits |
Hospice |
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. |
** Outpatient Care ** |
Doctor Office Visits |
$0 copay for each primary care doctor visit for Medicare-covered benefits. |
$0 copay for the cost of each in-area network urgent care Medicare-covered visit. |
$0 copay for each specialist doctor visit for Medicare-covered benefits. |
Chiropractic Services |
$0 copay for Medicare-covered chiropractic visits |
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 |
$0 copay for Medicare-covered podiatry benefits. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
$0 copay for Medicare-covered Mental Health visits |
$0 copay for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
$0 copay for Medicare-covered visits |
Outpatient Services/Surgery |
$0 copay for each Medicare-covered ambulatory surgical center visit |
$0 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
$0 copay for Medicare-covered ambulance benefits. |
Emergency Care |
$0 copay for Medicare-covered emergency room visits |
$20 000 plan coverage limit for emergency services outside the U.S. every year. |
Urgently Needed Care |
$0 copay for Medicare-covered urgently-needed-care visits |
Outpatient Rehabilitation Services |
There may be limits on physical therapy occupational therapy and speech and language pathology services If so there may be exceptions to these limits. |
$0 copay for Medicare-covered Occupational Therapy visits |
$0 copay for Medicare-covered Physical and/or Speech and Language Therapy visits |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
$0 copay for Medicare-covered items |
Prosthetic Devices |
0% of the cost for Medicare-covered items |
Diabetes Programs and Supplies |
$0 copay for Diabetes self-management training |
$0 copay for: |
Diabetes monitoring supplies |
Therapeutic shoes or inserts |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
$0 copay for Medicare-covered: |
lab services |
diagnostic procedures and tests |
X-rays |
diagnostic radiology services (not including X-rays) |
therapeutic radiology services |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
$0 copay for: |
Medicare-covered Cardiac Rehabilitation Services |
Medicare-covered Intensive Cardiac Rehabilitation Services |
Medicare-covered Pulmonary Rehabilitation Services |
Preventive Services and Wellness/Education Programs |
$0 copay for all preventive services covered under Original Medicare at zero cost sharing: Abdominal Aortic Aneurysm screening Bone Mass Measurement Cardiovascular Screening Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam) Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine HIV Screening Breast Cancer Screening (Mammogram) Medical Nutrition Therapy Services Personalized Prevention Plan Services (Annual Wellness Visits) Pneumococcal Vaccine Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only) Smoking Cessation (Counseling to stop smoking) Welcome to Medicare Physical Exam (Initial Preventive Physical Exam) |
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. Please contact plan for details. |
The plan covers the following supplemental education/wellness programs: |
Written health education materials including Newsletters |
Additional Smoking Cessation |
Health Club Membership/Fitness Classes |
Nursing Hotline |
Kidney Disease and Conditions |
Cost plan members pay Fee-for-Service cost sharing for out-of-area dialysis. |
$0 copay for renal dialysis |
$0 copay for kidney disease education services |
Outpatient Prescription Drugs |
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.medica.com/C12/DrugFormularyPartD/default.aspx on the web. |
Different out-of-pocket costs may apply for people who have limited incomes live in long term care facilities or have access to Indian/Tribal/Urban (Indian Health Service) providers. |
The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). |
Total yearly drug costs are the total drug costs paid by both you and a Part D plan. |
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. |
Some drugs have quantity limits. |
Your provider must get prior authorization from Medica Prime Solution Enhanced w/Part D Option 1 (Cost) for certain drugs. |
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. |
$320 annual deductible. |
After you pay your yearly deductible you pay 25% until total yearly drug costs reach $2 930. |
You can get drugs the following way(s): |
one-month (31-day) supply |
three-month (90-day) supply |
You can get drugs the following way(s): |
one-month (31-day) supply |
You can get drugs the following way(s): |
three-month (90-day) supply |
After your total yearly drug costs reach $2 930 you receive a discount on brand name drugs and pay 86% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 700. |
After your yearly out-of-pocket drug costs reach $4 700 you pay the greater of: 5% coinsurance or $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs. |
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Medica Prime Solution Enhanced w/Part D Option 1 (Cost). |
You can get drugs the following way: |
one-month (31-day) supply |
After you pay your yearly deductible you will be reimbursed up to 75% of the actual cost for drugs purchased out-of-network until your total yearly drug costs reach $2 930. |
You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 700. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 700. |
After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share which is the greater of: 5% coinsurance or $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs. |
Dental Services |
In general preventive dental benefits (such as cleaning) not covered. However this plan covers preventive dental benefits for an extra cost (see 'Optional Benefits.') |
0% of the cost for Medicare-covered dental benefits |
Hearing Services |
$0 copay for Medicare-covered diagnostic hearing exams |
$0 copay for |
up to 1 supplemental routine hearing exam(s) every year |
up to 1 fitting-evaluation(s) for a hearing aid every year |
$0 copay for hearing aids. |
$400 plan coverage limit for supplemental routine hearing exams and hearing aids every year. |
** Additional Benefits ** |
Vision Services |
$0 copay for diagnosis and treatment for diseases and conditions of the eye |
and up to 1 supplemental routine eye exam(s) every year |
$30 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 copay for glasses |
$0 copay for contacts |
$125 plan coverage limit for eye wear every year. |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
This plan does not cover supplemental routine transportation. |
Acupuncture |
This plan does not cover Acupuncture. |
** Inpatient Care ** |
Inpatient Hospital Care |
No limit to the number of days covered by the plan each hospital stay. |
$0 copay |
** Outpatient Care ** |
Doctor Office Visits |
$0 copay for each primary care doctor visit for Medicare-covered benefits. |
$0 copay for the cost of each in-area network urgent care Medicare-covered visit. |
$0 copay for each specialist doctor visit for Medicare-covered benefits. |
Outpatient Services/Surgery |
$0 copay for each Medicare-covered ambulatory surgical center visit |
$0 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
$0 copay for Medicare-covered ambulance benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
$0 copay for Medicare-covered items |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
$0 copay for Medicare-covered: |
lab services |
diagnostic procedures and tests |
X-rays |
diagnostic radiology services (not including X-rays) |
therapeutic radiology services |
** Additional Benefits ** |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
This plan does not cover supplemental routine transportation. |
** Cost ** |
Premium and Other Important Information |
Package: 1 - Medica Senior Dental: |
$42.50 monthly premium in addition to your $155.50 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: Preventive Dental Comprehensive Dental |
$1 000 plan coverage limit every year for these benefits. |
** Important Information ** |
Package: 1 - Medica Senior Dental: |
$42.50 monthly premium in addition to your $155.50 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: Preventive Dental Comprehensive Dental |
$1 000 plan coverage limit every year for these benefits. |
** Preventive Services ** |
Dental Services |
Plan offers additional comprehensive dental benefits. |
$0 copay for the following preventive dental benefits: |
up to 2 oral exam(s) every year |
up to 2 cleaning(s) every year |
up to 1 dental x-ray(s) |
$1 000 plan coverage limit for dental benefits every year |
** Cost ** |
Premium and Other Important Information |
Package: 2 - Wisconsin Rider: |
$38 monthly premium in addition to your $155.50 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: Skilled Nursing Facility (SNF) Home Health Services End-Stage Renal Disease |
$30 000 plan coverage limit every year for these benefits. |
** Important Information ** |
Package: 2 - Wisconsin Rider: |
$38 monthly premium in addition to your $155.50 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: Skilled Nursing Facility (SNF) Home Health Services End-Stage Renal Disease |
$30 000 plan coverage limit every year for these benefits. |