** Cost ** |
Premium and Other Important Information |
$79.00 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 does not allow providers to balance bill (charging more than your cost share amount). |
Unless otherwise noted out-of-network services not covered. |
$5 000 out-of-pocket limit for Medicare-covered services. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. |
** Extra Benefits ** |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
This plan does not cover supplemental routine transportation. |
** Important Information ** |
Premium and Other Important Information |
$79.00 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 does not allow providers to balance bill (charging more than your cost share amount). |
Unless otherwise noted out-of-network services not covered. |
$5 000 out-of-pocket limit for Medicare-covered services. |
Doctor and Hospital Choice |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. |
** Inpatient Care ** |
Inpatient Hospital Care |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment except in emergencies. |
No limit to the number of days covered by the plan each hospital stay. |
For Medicare-covered hospital stays: |
Days 1 - 7: $225 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 of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. |
$1 400 copay for each Medicare-covered hospital stay. |
Skilled Nursing Facility (SNF) |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
For SNF stays: |
Days 1 - 20: $0 copay per day |
Days 21 - 100: $100 copay per day |
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 |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. |
$15 copay for each primary care doctor visit for Medicare-covered benefits. |
$35 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
$15 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 |
$35 copay for each Medicare-covered visit |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
$35 copay for each Medicare-covered individual therapy visit |
$35 copay for each Medicare-covered group therapy visit |
$35 copay for each Medicare-covered individual therapy visit with a psychiatrist |
$35 copay for each Medicare-covered group therapy visit with a psychiatrist |
20% of the cost for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
25% of the cost for Medicare-covered individual visits |
25% of the cost for Medicare-covered group visits |
Outpatient Services/Surgery |
20% of the cost for each Medicare-covered ambulatory surgical center visit |
20% to 25% of the cost for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
20% of the cost for Medicare-covered ambulance benefits. |
Emergency Care |
$65 copay for Medicare-covered emergency room visits |
$25 000 plan coverage limit for emergency services outside the U.S. every year. |
Urgently Needed Care |
Cost sharing is the same as Doctor Office Visit cost sharing. |
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. |
$35 copay [or 25% of the cost] for Medicare-covered Occupational Therapy visits |
$35 copay [or 25% of the cost] for Medicare-covered Physical and/or Speech and Language Therapy visits |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
20% of the cost for Medicare-covered items |
20% of the cost for durable medical equipment |
Prosthetic Devices |
20% of the cost for Medicare-covered items |
Diabetes Programs and Supplies |
$0 copay for Diabetes self-management training |
0% to 20% of the cost for Diabetes monitoring supplies |
$10 copay for Therapeutic shoes or inserts |
20% of the cost for Diabetes monitoring supplies |
20% of the cost for Therapeutic shoes or inserts |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
$0 to $35 copay [or 0% to 25% of the cost] for Medicare-covered lab services |
$0 to $35 copay [or 0% to 25% of the cost] for Medicare-covered diagnostic procedures and tests |
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered X-rays |
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) |
$35 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services |
0% to 25% of the cost for diagnostic procedures tests and lab services |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
$35 copay [or 25% of the cost] for Medicare-covered Cardiac Rehabilitation Services |
$35 copay [or 25% of the cost] for Medicare-covered Intensive Cardiac Rehabilitation Services |
$35 copay [or 20% to 25% of the cost] for 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 |
20% of the cost for renal dialysis |
$0 copay for kidney disease education services |
Outpatient Prescription Drugs |
Most drugs not covered. |
0% to 20% of the cost for Part B-covered drugs (not including Part B-covered chemotherapy drugs). |
20% of the cost for Part B-covered chemotherapy drugs. |
This plan does not offer prescription drug coverage. |
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.') |
$35 copay for Medicare-covered dental benefits |
Hearing Services |
In general supplemental routine hearing exams and hearing aids not covered. |
$35 copay for Medicare-covered diagnostic hearing exams |
** Additional Benefits ** |
Vision Services |
In general supplemental routine eye exams and eye wear not covered. However this plan covers some vision benefits for an extra cost (see 'Optional Benefits'). |
$25 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. |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
This plan does not cover supplemental routine transportation. |
Acupuncture |
This plan does not cover Acupuncture. |
** Inpatient Care ** |
Inpatient Hospital Care |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment except in emergencies. |
No limit to the number of days covered by the plan each hospital stay. |
For Medicare-covered hospital stays: |
Days 1 - 7: $225 copay per day |
Days 8 - 90: $0 copay per day |
$0 copay for each additional hospital day. |
** Outpatient Care ** |
Doctor Office Visits |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. |
$15 copay for each primary care doctor visit for Medicare-covered benefits. |
$35 copay for each specialist visit for Medicare-covered benefits. |
Outpatient Services/Surgery |
20% of the cost for each Medicare-covered ambulatory surgical center visit |
20% to 25% of the cost for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
20% of the cost for Medicare-covered ambulance benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
20% of the cost for Medicare-covered items |
20% of the cost for durable medical equipment |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
$0 to $35 copay [or 0% to 25% of the cost] for Medicare-covered lab services |
$0 to $35 copay [or 0% to 25% of the cost] for Medicare-covered diagnostic procedures and tests |
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered X-rays |
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) |
$35 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services |
0% to 25% of the cost for diagnostic procedures tests and lab services |
** Additional Benefits ** |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
This plan does not cover supplemental routine transportation. |
** Cost ** |
Premium and Other Important Information |
Package: 1 - MyOption Dental High PPO: |
$22 monthly premium in addition to your $79 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: Preventive Dental Comprehensive Dental |
$1 500 plan coverage limit every year for these benefits. |
** Important Information ** |
Package: 1 - MyOption Dental High PPO: |
$22 monthly premium in addition to your $79 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: Preventive Dental Comprehensive Dental |
$1 500 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) every year |
30% of the cost for preventive dental services |
55% to 75% of the cost for comprehensive dental services |
$1 500 plan coverage limit for comprehensive dental benefits every year. This limit applies to both in-network and out-of-network benefits. |
$1 500 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits. |
** Cost ** |
Premium and Other Important Information |
Package: 2 - MyOption Dental Low PPO: |
$14 monthly premium in addition to your $79 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: 2 - MyOption Dental Low PPO: |
$14 monthly premium in addition to your $79 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) every year |
30% of the cost for preventive dental services |
55% of the cost for comprehensive dental services |
$1 000 plan coverage limit for comprehensive dental benefits every year. This limit applies to both in-network and out-of-network benefits. |
$1 000 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits. |
** Cost ** |
Premium and Other Important Information |
Package: 3 - MyOption Vision: |
$15 monthly premium in addition to your $79 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: Eye Exams Eye Wear |
$290 plan coverage limit every year for these benefits. |
** Important Information ** |
Package: 3 - MyOption Vision: |
$15 monthly premium in addition to your $79 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: Eye Exams Eye Wear |
$290 plan coverage limit every year for these benefits. |
** Additional Benefits ** |
Vision Services |
$0 copay for up to 1 pair(s) of contacts every year |
$0 copay for up to 1 pair(s) of lenses every year |
$0 copay for up to 1 pair(s) of glasses every year |
$0 copay for up to 1 frame(s) every year |
$0 copay for up to 1 supplemental routine eye exam(s) every year |
** Cost ** |
Premium and Other Important Information |
Package: 4 - MyOption Plus: |
$25 monthly premium in addition to your $79 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: Preventive Dental Comprehensive Dental Eye Exams Eye Wear |
** Important Information ** |
Package: 4 - MyOption Plus: |
$25 monthly premium in addition to your $79 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: Preventive Dental Comprehensive Dental Eye Exams Eye Wear |
** 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) every year |
30% of the cost for preventive dental services |
55% of the cost for comprehensive dental services |
$1 000 plan coverage limit for comprehensive dental benefits every year. This limit applies to both in-network and out-of-network benefits. |
$1 000 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits. |
** Additional Benefits ** |
Vision Services |
$0 copay for up to 1 pair(s) of contacts every year |
$0 copay for up to 1 pair(s) of lenses every year |
$0 copay for up to 1 pair(s) of glasses every year |
$0 copay for up to 1 frame(s) every year |
$0 copay for up to 1 supplemental routine eye exam(s) every year |