** 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. |
$2 500 out-of-pocket limit for Medicare-covered services. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
No referral required for network doctors specialists and hospitals. |
** 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 |
$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. |
$2 500 out-of-pocket limit for Medicare-covered services. |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
No referral required for network doctors specialists and hospitals. |
** Inpatient Care ** |
Inpatient Hospital Care |
No limit to the number of days covered by the plan each hospital stay. |
$0 copay |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Inpatient Mental Health Care |
$0 copay |
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. |
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 |
3-day prior hospital stay is required. |
$0 copay for SNF services |
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 |
$0 copay for each primary care doctor visit for Medicare-covered benefits. |
$5 copay for each in-area network urgent care Medicare-covered visit |
$0 copay for each specialist doctor visit for Medicare-covered benefits. |
Chiropractic Services |
Authorization rules may apply. |
$0 copay for: Medicare-covered chiropractic visits |
up to 5 supplemental routine visit(s) every year |
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. |
$0 copay for Medicare-covered podiatry visits |
up to 4 supplemental routine visit(s) every year |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$0 copay for Medicare-covered Mental Health visits |
$0 copay for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$0 copay for Medicare-covered visits |
Outpatient Services/Surgery |
Authorization rules may apply. |
$0 copay for each Medicare-covered ambulatory surgical center visit |
$0 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
Authorization rules may apply. |
$0 copay for Medicare-covered ambulance benefits. |
Emergency Care |
$50 copay for Medicare-covered emergency room visits |
Worldwide coverage. |
If you are admitted to the hospital within 1-day for the same condition you pay $0 for the emergency room visit. |
Urgently Needed Care |
$5 to $25 copay for Medicare-covered urgently-needed-care visits |
If you are admitted to the hospital within 1-day for the same condition you pay $0 for the urgently-needed-care visit. |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
There may be limits on physical therapy occupational therapy and speech and language pathology services If so there may be exceptions to these limits. |
$0 copay for Medicare-covered Occupational Therapy visits |
$0 copay for Medicare-covered Physical and/or Speech and Language Therapy visits |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
10% of the cost for Medicare-covered items |
Prosthetic Devices |
Authorization rules may apply. |
10% of the cost for Medicare-covered items |
Diabetes Programs and Supplies |
Authorization rules may apply. |
$0 copay for Diabetes self-management training |
$0 copay for: |
Diabetes monitoring supplies |
Therapeutic shoes or inserts |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
Authorization rules may apply. |
$0 copay for Medicare-covered: |
lab services |
diagnostic procedures and tests |
$0 copay for Medicare-covered X-rays |
$0 to $25 copay for Medicare-covered diagnostic radiology services (not including X-rays) |
$0 to $25 copay for Medicare-covered therapeutic radiology services |
** 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. |
Authorization rules may apply. |
The plan covers the following supplemental education/wellness programs: |
Additional Smoking Cessation |
Health Club Membership/Fitness Classes |
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. |
5% 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 |
Authorization rules may apply. |
$0 copay for Medicare-covered dental benefits |
$5 copay for up to 2 oral exam(s) every year |
$5 copay for up to 2 cleaning(s) every year |
$5 copay for up to 2 fluoride treatment(s) every year |
$5 copay for up to 2 dental x-ray(s) every year |
Plan offers additional comprehensive dental benefits. |
$750 plan coverage limit for comprehensive dental benefits every year |
Hearing Services |
Authorization rules may apply. |
$0 copay for Medicare-covered diagnostic hearing exams |
$0 copay for |
up to 1 supplemental routine hearing exam(s) every year |
up to 1 fitting-evaluation(s) for a hearing aid every year |
$0 copay for up to 1 hearing aid(s) every year |
$300 plan coverage limit for hearing aids every three years. |
** Additional Benefits ** |
Vision Services |
Authorization rules may apply. |
$0 copay for diagnosis and treatment for diseases and conditions of the eye |
and up to 1 supplemental routine eye exam(s) every year |
$0 copay for one pair of eyeglasses or contact lenses after cataract surgery |
up to 1 pair(s) of glasses every year |
up to 1 pair(s) of contacts every year |
up to 1 pair(s) of lenses every year |
up to 1 frame(s) every year |
$100 plan coverage limit for eye wear every year. |
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 |
Authorization rules may apply. |
$5 copay per visit up to 6 visit(s) every year |
** Inpatient Care ** |
Inpatient Hospital Care |
No limit to the number of days covered by the plan each hospital stay. |
$0 copay |
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 |
$0 copay for each primary care doctor visit for Medicare-covered benefits. |
$5 copay for each in-area network urgent care Medicare-covered visit |
$0 copay for each specialist doctor visit for Medicare-covered benefits. |
Outpatient Services/Surgery |
Authorization rules may apply. |
$0 copay for each Medicare-covered ambulatory surgical center visit |
$0 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
Authorization rules may apply. |
$0 copay for Medicare-covered ambulance benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
10% of the cost for Medicare-covered items |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
Authorization rules may apply. |
$0 copay for Medicare-covered: |
lab services |
diagnostic procedures and tests |
$0 copay for Medicare-covered X-rays |
$0 to $25 copay for Medicare-covered diagnostic radiology services (not including X-rays) |
$0 to $25 copay for Medicare-covered therapeutic radiology 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. |