| ** Cost ** |
| Premium and Other Important Information |
| $30.00 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). |
| $4 000 out-of-pocket limit. All plan services included. |
| ** 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 |
| $30.00 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). |
| $4 000 out-of-pocket limit. All plan services included. |
| 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: $125 copay per day |
| Days 8 - 60: $0 copay per day |
| Days 61 - 90: $100 copay per day |
| $100 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. |
| For Medicare-covered hospital stays: |
| Days 1 - 7: $175 copay per day |
| Days 8 - 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: $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. |
| $10 copay for each primary care doctor visit for Medicare-covered benefits. |
| $30 copay for each specialist visit for Medicare-covered benefits. |
| 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. |
| Podiatry Services |
| $30 copay for each Medicare-covered visit |
| Medicare-covered podiatry benefits are for medically-necessary foot care. |
| Outpatient Mental Health Care |
| $30 copay for each Medicare-covered individual therapy visit |
| $20 copay for each Medicare-covered group therapy visit |
| $30 copay for each Medicare-covered individual therapy visit with a psychiatrist |
| $20 copay for each Medicare-covered group therapy visit with a psychiatrist |
| $65 copay for Medicare-covered partial hospitalization program services |
| Outpatient Substance Abuse Care |
| $30 copay for Medicare-covered individual visits |
| $20 copay for Medicare-covered group visits |
| Outpatient Services/Surgery |
| $0 to $300 copay [or 20% of the cost] for each Medicare-covered ambulatory surgical center visit |
| $0 to $300 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit |
| Ambulance Services |
| $150 copay for Medicare-covered ambulance benefits. |
| If you are admitted to the hospital you pay $0 for Medicare-covered ambulance benefits. |
| Emergency Care |
| $65 copay for Medicare-covered emergency room visits |
| Worldwide coverage. |
| 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. |
| $30 copay for Medicare-covered Occupational Therapy visits |
| $30 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 |
| $30 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 |
| 'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
| $0 copay for Medicare-covered: |
| lab services |
| diagnostic procedures and tests |
| 0% of the cost for Medicare-covered X-rays |
| 0% to 15% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) |
| 15% 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 $10 to $30 may apply |
| If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $10 to $30 may apply |
| ** 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: |
| Health Club Membership/Fitness Classes |
| Kidney Disease and Conditions |
| $0 copay for renal dialysis |
| $30 copay for kidney disease education services |
| Outpatient Prescription Drugs |
| Most drugs not covered. |
| 20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
| This plan does not offer prescription drug coverage. |
| Dental Services |
| $0 copay for Medicare-covered dental benefits |
| $0 copay for the following preventive dental benefits: |
| oral exams |
| cleanings |
| fluoride treatments |
| dental x-rays |
| Plan offers additional comprehensive dental benefits. |
| $200 plan coverage limit for dental benefits every year. This limit applies to both in-network and out-of-network benefits. |
| Hearing Services |
| Hearing aids not covered. |
| $10 to $30 copay for Medicare-covered diagnostic hearing exams |
| $30 copay for up to 1 supplemental routine hearing exam(s) every year |
| ** Additional Benefits ** |
| Vision Services |
| 20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery. |
| $10 to $30 copay for exams to diagnose and treat diseases and conditions of the eye. |
| $30 copay for up to 1 supplemental routine eye exam(s) every year |
| 0% of the cost for glasses |
| 0% of the cost for contacts |
| 0% of the cost for lenses |
| 0% of the cost for frames |
| $200 plan coverage limit for eye wear every year. 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 |
| 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: $125 copay per day |
| Days 8 - 60: $0 copay per day |
| Days 61 - 90: $100 copay per day |
| $100 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. |
| $10 copay for each primary care doctor visit for Medicare-covered benefits. |
| $30 copay for each specialist visit for Medicare-covered benefits. |
| Outpatient Services/Surgery |
| $0 to $300 copay [or 20% of the cost] for each Medicare-covered ambulatory surgical center visit |
| $0 to $300 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit |
| Ambulance Services |
| $150 copay for Medicare-covered ambulance benefits. |
| If you are admitted to the hospital you pay $0 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' |
| $0 copay for Medicare-covered: |
| lab services |
| diagnostic procedures and tests |
| 0% of the cost for Medicare-covered X-rays |
| 0% to 15% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) |
| 15% 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 $10 to $30 may apply |
| If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $10 to $30 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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