** Cost ** |
Premium and Other Important Information |
$28.00 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. |
Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept 'assignment' from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare 'assignment ' your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare 'limiting charge.' If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare 'limiting charge' does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to 'assignment' and 'limiting charges' that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.gov/physician or www.medicare.gov/supplier. You can also call 1-800 |
$195 annual deductible. Contact the plan for services that apply. |
$2 550 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. |
$195 annual deductible. Contact the plan for services that apply. |
$5 100 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
** 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 |
$28.00 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. |
Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept 'assignment' from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare 'assignment ' your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare 'limiting charge.' If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare 'limiting charge' does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to 'assignment' and 'limiting charges' that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.gov/physician or www.medicare.gov/supplier. You can also call 1-800 |
$195 annual deductible. Contact the plan for services that apply. |
$2 550 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. |
$195 annual deductible. Contact the plan for services that apply. |
$5 100 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
** Inpatient Care ** |
Inpatient Hospital Care |
No limit to the number of days covered by the plan each hospital stay. |
$275 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. |
20% of the cost for each hospital stay. |
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. |
$275 copay for each Medicare-covered hospital stay. |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
20% of the cost for each hospital stay. |
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 - 6: $0 copay per day |
Days 7 - 40: $75 copay per day |
Days 41 - 100: $0 copay per day |
20% of the cost for each SNF stay. |
Home Health Care |
Authorization rules may apply. |
$0 copay for Medicare-covered home health visits |
20% of the cost for 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 |
$10 copay for each primary care doctor visit for Medicare-covered benefits. |
$10 copay for each in-area network urgent care Medicare-covered visit |
$25 copay for each specialist visit for Medicare-covered benefits. |
$20 copay for each primary care doctor visit |
$35 copay for each specialist visit |
Chiropractic Services |
$20 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. |
$35 copay for chiropractic benefits. |
Podiatry Services |
$25 copay for each Medicare-covered visit |
$0 copay for up to 4 supplemental routine visit(s) every year |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
$35 copay for podiatry benefits. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$25 copay for each Medicare-covered individual therapy visit |
$10 copay for each Medicare-covered group therapy visit |
$25 copay for each Medicare-covered individual therapy visit with a psychiatrist |
$10 copay for each Medicare-covered group therapy visit with a psychiatrist |
$25 copay for Medicare-covered partial hospitalization program services |
20% of the cost for Mental Health benefits with a psychiatrist |
20% of the cost for Mental Health benefits |
20% of the cost for partial hospitalization program services |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$25 copay for Medicare-covered individual visits |
$10 copay for Medicare-covered group visits |
20% of the cost for outpatient substance abuse benefits. |
Outpatient Services/Surgery |
Authorization rules may apply. |
$125 copay for each Medicare-covered ambulatory surgical center visit |
$125 copay for each Medicare-covered outpatient hospital facility visit |
20% of the cost for outpatient hospital facility benefits. |
20% of the cost for ambulatory surgical center benefits. |
Ambulance Services |
$100 copay for Medicare-covered ambulance benefits. |
If you are admitted to the hospital you pay $0 for Medicare-covered ambulance benefits. |
20% of the cost for ambulance benefits. |
Emergency Care |
$50 copay for Medicare-covered emergency room visits |
This amount applies toward your in-network plan deductible. |
This amount applies toward your out-of-network plan deductible. |
Worldwide coverage. |
If you are admitted to the hospital within 3-day(s) for the same condition you pay $0 for the emergency room visit. |
Urgently Needed Care |
$25 copay for Medicare-covered urgently-needed-care visits |
If you are admitted to the hospital within 3-day(s) for the same condition you pay $0 for the urgently-needed-care visit. |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
$25 copay for Medicare-covered Occupational Therapy visits |
$25 copay for Medicare-covered Physical and/or Speech and Language Therapy visits |
20% of the cost for Physical and/or Speech and Language Therapy visits |
20% of the cost for Occupational Therapy benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
20% of the cost for Medicare-covered items |
20% of the cost for durable medical equipment |
Prosthetic Devices |
Authorization rules may apply. |
20% of the cost for Medicare-covered items |
20% of the cost for prosthetic devices. |
Diabetes Programs and Supplies |
Authorization rules may apply. |
$0 copay for Diabetes self-management training |
0% to 20% of the cost for Diabetes monitoring supplies |
20% of the cost for Therapeutic shoes or inserts |
20% of the cost for Diabetes self-management training |
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' |
Authorization rules may apply. |
$0 to $10 copay for Medicare-covered lab services |
$0 to $10 copay for Medicare-covered diagnostic procedures and tests |
$45 copay for Medicare-covered X-rays |
$45 to $125 copay for Medicare-covered diagnostic radiology services (not including X-rays) |
$45 copay for Medicare-covered therapeutic radiology services |
20% of the cost for therapeutic radiology services |
20% of the cost for outpatient X-rays |
20% of the cost for diagnostic radiology services |
20% of the cost for diagnostic procedures tests and lab services |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
Authorization rules may apply. |
$25 copay for Medicare-covered Cardiac Rehabilitation Services |
$25 copay for Medicare-covered Intensive Cardiac Rehabilitation Services |
$25 copay for Medicare-covered Pulmonary Rehabilitation Services |
20% of the cost for Cardiac Rehabilitation Services |
20% of the cost for Intensive Cardiac Rehabilitation Services |
20% of the cost for 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 |
Health Club Membership/Fitness Classes |
Nursing Hotline |
$35 copay for Medicare-covered preventive services |
20% of the cost for supplemental education/wellness programs |
Kidney Disease and Conditions |
Authorization rules may apply. |
$0 copay for renal dialysis |
$0 copay for kidney disease education services |
20% of the cost for kidney disease education services |
20% of the cost for renal dialysis |
Outpatient Prescription Drugs |
Most drugs not covered. |
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
20% of the cost for Part B drugs out-of-network. |
This plan does not offer prescription drug coverage. |
Dental Services |
Authorization rules may apply. |
$0 copay for Medicare-covered dental benefits |
$20 copay for an office visit that includes: |
up to 1 oral exam(s) every six months |
up to 1 cleaning(s) every six months |
$20 to $30 copay for up to 1 dental x-ray(s) every year |
$35 copay for comprehensive dental benefits |
20% of the cost for preventive dental benefits |
Hearing Services |
$25 copay for Medicare-covered diagnostic hearing exams |
$25 copay for up to 1 supplemental routine hearing exam(s) every year |
$0 copay for up to 1 hearing aid fitting-evaluation(s) every three years |
$0 copay for up to 1 hearing aid(s) every three years |
$35 copay for hearing exams. |
$0 copay for hearing aids. |
$800 plan coverage limit for supplemental routine hearing aids every three years. This limit applies to both in-network and out-of-network benefits. |
** Additional Benefits ** |
Vision Services |
$0 copay 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 supplemental routine eye exam(s) every year |
$0 copay for up to 1 pair(s) of glasses every two years |
$0 copay for up to 1 pair(s) of contacts every two years |
$35 copay for eye exams. |
$0 copay for eye wear. |
The plan will pay up to $200 for all of the following services combined: Eye Wear |
$200 plan coverage limit for eye wear every two years. This limit applies to both in-network and out-of-network benefits. |
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. |
$275 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. |
20% of the cost for each hospital stay. |
** Outpatient Care ** |
Doctor Office Visits |
$10 copay for each primary care doctor visit for Medicare-covered benefits. |
$10 copay for each in-area network urgent care Medicare-covered visit |
$25 copay for each specialist visit for Medicare-covered benefits. |
$20 copay for each primary care doctor visit |
$35 copay for each specialist visit |
Outpatient Services/Surgery |
Authorization rules may apply. |
$125 copay for each Medicare-covered ambulatory surgical center visit |
$125 copay for each Medicare-covered outpatient hospital facility visit |
20% of the cost for outpatient hospital facility benefits. |
20% of the cost for ambulatory surgical center benefits. |
Ambulance Services |
$100 copay for Medicare-covered ambulance benefits. |
If you are admitted to the hospital you pay $0 for Medicare-covered ambulance benefits. |
20% of the cost for ambulance benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
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' |
Authorization rules may apply. |
$0 to $10 copay for Medicare-covered lab services |
$0 to $10 copay for Medicare-covered diagnostic procedures and tests |
$45 copay for Medicare-covered X-rays |
$45 to $125 copay for Medicare-covered diagnostic radiology services (not including X-rays) |
$45 copay for Medicare-covered therapeutic radiology services |
20% of the cost for therapeutic radiology services |
20% of the cost for outpatient X-rays |
20% of the cost for diagnostic radiology services |
20% of the cost for diagnostic procedures tests and lab 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. |