| ** Cost ** |
| Premium and Other Important Information |
| $82 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. |
| This plan does not allow providers to balance bill (charging more than your cost share amount). |
| $6 700 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 |
| 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 |
| $82 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. |
| This plan does not allow providers to balance bill (charging more than your cost share amount). |
| $6 700 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 - 6: $235 copay per day |
| Days 7 - 90: $0 copay per day |
| $0 copay for additional hospital days |
| 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. |
| For Medicare-covered hospital stays: |
| Days 1 - 6: $235 copay per day |
| Days 7 - 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 SNF stays: |
| Days 1 - 20: $0 copay per day |
| Days 21 - 100: $135 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. |
| $25 copay for each primary care doctor visit for Medicare-covered benefits. |
| $50 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 |
| $50 copay for each Medicare-covered visit |
| Medicare-covered podiatry benefits are for medically-necessary foot care. |
| Outpatient Mental Health Care |
| 40% of the cost for each Medicare-covered individual therapy visit |
| 40% of the cost for each Medicare-covered group therapy visit |
| 40% of the cost for each Medicare-covered individual therapy visit with a psychiatrist |
| 40% of the cost for each Medicare-covered group therapy visit with a psychiatrist |
| $265 copay for Medicare-covered partial hospitalization program services |
| Outpatient Substance Abuse Care |
| 40% of the cost for Medicare-covered individual visits |
| 40% of the cost for Medicare-covered group visits |
| Outpatient Services/Surgery |
| $150 copay for each Medicare-covered ambulatory surgical center visit |
| $300 copay for each Medicare-covered outpatient hospital facility visit |
| Ambulance Services |
| $150 copay for Medicare-covered ambulance benefits. |
| Emergency Care |
| $65 copay for Medicare-covered emergency room visits |
| $20 000 plan coverage limit for emergency services outside the U.S. every year. |
| If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit. |
| 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. |
| $45 copay for Medicare-covered Occupational Therapy visits |
| $45 copay 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 |
| 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 |
| 20% of the cost for Therapeutic shoes or inserts |
| If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $25 to $50 may apply |
| 'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
| 20% of the cost for Medicare-covered lab services |
| 20% of the cost for Medicare-covered diagnostic procedures and tests |
| 20% of the cost for Medicare-covered X-rays |
| 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) |
| 20% of the cost for Medicare-covered therapeutic radiology services |
| If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $25 to $50 may apply |
| If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $25 to $50 may apply |
| ** Preventive Services ** |
| Cardiac and Pulmonary Rehabilitation Services |
| $45 copay for Medicare-covered Cardiac Rehabilitation Services |
| $45 copay for Medicare-covered Intensive Cardiac Rehabilitation Services |
| $45 copay 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 |
| Nursing Hotline |
| Kidney Disease and Conditions |
| $30 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 www.TodaysOptions.com 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 Today's Options Premier Plus 450D (PFFS) 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. |
| If you request a formulary exception for a drug and Today's Options Premier Plus 450D (PFFS) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug. |
| $50 annual deductible. |
| After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 930: |
| Tier 1: Generic Drugs |
| Tier 2: Preferred Brand Drugs |
| Tier 3: Non-Preferred Brand Drugs |
| Tier 4: Specialty Tier Drugs |
| $10 copay for a one-month (30-day) supply of drugs in this tier |
| $45 copay for a one-month (30-day) supply of drugs in this tier |
| $95 copay for a one-month (30-day) supply of drugs in this tier |
| 29% coinsurance for a one-month (30-day) supply of drugs in this tier |
| $25 copay for a three-month (90-day) supply of drugs in this tier |
| $112.50 copay for a three-month (90-day) supply of drugs in this tier |
| $237.50 copay for a three-month (90-day) supply of drugs in this tier |
| 29% coinsurance for a three-month (90-day) supply of drugs in this tier |
| Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
| Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
| Tier 1: Generic Drugs |
| Tier 2: Preferred Brand Drugs |
| Tier 3: Non-Preferred Brand Drugs |
| Tier 4: Specialty Tier Drugs |
| $10 copay for a one-month (34-day) supply of drugs in this tier |
| $45 copay for a one-month (34-day) supply of drugs in this tier |
| $95 copay for a one-month (34-day) supply of drugs in this tier |
| 29% coinsurance for a one-month (34-day) supply of drugs in this tier |
| 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 Today's Options Premier Plus 450D (PFFS). |
| After you pay your yearly deductible you will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until your total yearly drug costs reach $2 930: |
| Tier 1: Generic Drugs |
| Tier 2: Preferred Brand Drugs |
| Tier 3: Non-Preferred Brand Drugs |
| Tier 4: Specialty Tier Drugs |
| $10 copay for a one-month (30-day) supply of drugs in this tier |
| $45 copay for a one-month (30-day) supply of drugs in this tier |
| $95 copay for a one-month (30-day) supply of drugs in this tier |
| 29% coinsurance for a one-month (30-day) supply of drugs in this tier |
| 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 |
| $0 copay for Medicare-covered dental benefits |
| In general preventive dental benefits (such as cleaning) not covered. |
| Hearing Services |
| Hearing aids not covered. |
| $20 copay for Medicare-covered diagnostic hearing exams |
| $20 copay for up to 1 supplemental routine hearing exam(s) every year |
| ** Additional Benefits ** |
| Vision Services |
| $20 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
| $20 copay for exams to diagnose and treat diseases and conditions of the eye. |
| $20 copay for up to 1 supplemental routine eye exam(s) 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 |
| 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 - 6: $235 copay per day |
| Days 7 - 90: $0 copay per day |
| $0 copay for additional hospital days |
| ** Outpatient Care ** |
| Doctor Office Visits |
| You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. |
| $25 copay for each primary care doctor visit for Medicare-covered benefits. |
| $50 copay for each specialist visit for Medicare-covered benefits. |
| Outpatient Services/Surgery |
| $150 copay for each Medicare-covered ambulatory surgical center visit |
| $300 copay for each Medicare-covered outpatient hospital facility visit |
| Ambulance Services |
| $150 copay for Medicare-covered ambulance benefits. |
| ** Outpatient Medical Services and Supplies ** |
| Durable Medical Equipment |
| 20% of the cost for Medicare-covered items |
| 'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
| 20% of the cost for Medicare-covered lab services |
| 20% of the cost for Medicare-covered diagnostic procedures and tests |
| 20% of the cost for Medicare-covered X-rays |
| 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) |
| 20% of the cost for Medicare-covered therapeutic radiology services |
| If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $25 to $50 may apply |
| If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $25 to $50 may apply |
| ** Additional Benefits ** |
| Over-the-Counter Items |
| The plan does not cover Over-the-Counter items. |
| Transportation |
| This plan does not cover supplemental routine transportation. |
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