** Cost ** |
Premium and Other Important Information |
$0.00 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. |
$3 100 out-of-pocket limit. All plan services included. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network hospitals and specialists (for certain 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 |
$0.00 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. |
$3 100 out-of-pocket limit. All plan services included. |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network hospitals and specialists (for certain benefits). |
** Inpatient Care ** |
Inpatient Hospital Care |
No limit to the number of days covered by the plan each hospital stay. |
For Medicare-covered hospital stays: |
Days 1 - 5: $150 copay per day |
Days 6 - 90: $0 copay per day |
$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. |
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 - 5: $150 copay per day |
Days 6 - 90: $0 copay per day |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
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 - 30: $0 copay per day |
Days 31 - 100: $100 copay per day |
Home Health Care |
Authorization rules may apply. |
$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 |
Authorization rules may apply. |
$10 copay for each primary care doctor visit for Medicare-covered benefits. |
$15 copay for each in-area network urgent care Medicare-covered visit |
$30 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
Authorization rules may apply. |
$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 |
Authorization rules may apply. |
$10 copay for each Medicare-covered visit |
$10 copay for up to 6 supplemental routine visit(s) every year |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$30 copay for each Medicare-covered individual therapy visit |
$30 copay for each Medicare-covered group therapy visit |
$30 copay for each Medicare-covered individual therapy visit with a psychiatrist |
$30 copay for each Medicare-covered group therapy visit with a psychiatrist |
$30 copay for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$30 copay for Medicare-covered individual visits |
$30 copay for Medicare-covered group visits |
Outpatient Services/Surgery |
Authorization rules may apply. |
$125 copay for each Medicare-covered ambulatory surgical center visit |
$0 to $125 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
Authorization rules may apply. |
$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 |
$15 copay for Medicare-covered urgently-needed-care visits |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the urgently-needed-care visit. |
Outpatient Rehabilitation Services |
$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 |
Authorization rules may apply. |
20% of the cost for Medicare-covered items |
Prosthetic Devices |
Authorization rules may apply. |
20% of the cost for Medicare-covered items |
Diabetes Programs and Supplies |
$0 copay for Diabetes self-management training |
$10 copay for Diabetes monitoring supplies |
$10 copay for Therapeutic shoes or inserts |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
Authorization rules may apply. |
0% of the cost for Medicare-covered lab services |
0% to 20% of the cost for Medicare-covered diagnostic procedures and tests |
$0 copay for Medicare-covered X-rays |
$125 copay 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 $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 |
Authorization rules may apply. |
$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: |
Additional Smoking Cessation |
Health Club Membership/Fitness Classes |
Nursing Hotline |
Kidney Disease and Conditions |
Authorization rules may apply. |
$0 copay for renal dialysis |
$0 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 the following preventive dental benefits: |
oral exams |
cleanings |
fluoride treatments |
dental x-rays |
$30 copay for Medicare-covered dental benefits |
Plan offers additional comprehensive dental benefits. |
$500 plan coverage limit for dental benefits every year |
Hearing Services |
Hearing aids not covered. |
$30 copay for Medicare-covered diagnostic hearing exams |
$10 copay for up to 1 supplemental routine hearing exam(s) every year |
** Additional Benefits ** |
Vision Services |
$0 copay for one pair of eyeglasses or contact lenses after cataract surgery |
up to 1 pair(s) of glasses |
up to 1 pair(s) of contacts |
$0 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 |
$150 plan coverage limit for eye wear every two years. |
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. |
For Medicare-covered hospital stays: |
Days 1 - 5: $150 copay per day |
Days 6 - 90: $0 copay per day |
$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. |
** Outpatient Care ** |
Doctor Office Visits |
Authorization rules may apply. |
$10 copay for each primary care doctor visit for Medicare-covered benefits. |
$15 copay for each in-area network urgent care Medicare-covered visit |
$30 copay for each specialist visit for Medicare-covered benefits. |
Outpatient Services/Surgery |
Authorization rules may apply. |
$125 copay for each Medicare-covered ambulatory surgical center visit |
$0 to $125 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
Authorization rules may apply. |
$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 |
Authorization rules may apply. |
20% of the cost for Medicare-covered items |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
Authorization rules may apply. |
0% of the cost for Medicare-covered lab services |
0% to 20% of the cost for Medicare-covered diagnostic procedures and tests |
$0 copay for Medicare-covered X-rays |
$125 copay 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 $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. |