** Cost ** |
Premium and Other Important Information |
$62.00 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. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. |
Plan covers you when you travel in the U.S. |
** 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 |
$62.00 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. |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. |
Plan covers you when you travel in the U.S. |
** Inpatient Care ** |
Inpatient Hospital Care |
No limit to the number of days covered by the plan each hospital stay. |
$0 copay |
$300 out-of-pocket limit every benefit period. |
Inpatient Mental Health Care |
$0 copay |
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. |
$300 out-of-pocket limit every benefit period. |
Skilled Nursing Facility (SNF) |
Plan covers up to 100 days each benefit period |
$0 copay for SNF services |
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 |
20% of the cost for each primary care doctor visit for Medicare-covered benefits. |
20% of the cost for each in-area network urgent care Medicare-covered visit |
20% of the cost for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
20% 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 |
20% of the cost for each Medicare-covered visit |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
20% of the cost for each Medicare-covered individual therapy visit |
20% of the cost for each Medicare-covered group therapy visit |
20% of the cost for each Medicare-covered individual therapy visit with a psychiatrist |
20% of the cost for each Medicare-covered group therapy visit with a psychiatrist |
20% of the cost for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
20% of the cost for Medicare-covered individual visits |
20% of the cost for Medicare-covered group visits |
Outpatient Services/Surgery |
20% of the cost for each Medicare-covered ambulatory surgical center visit |
20% of the cost for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
20% of the cost for Medicare-covered ambulance benefits. |
Emergency Care |
$100 copay for Medicare-covered emergency room visits |
Not covered outside the U.S. except under limited circumstances. Contact the plan for more details. |
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 |
20% of the cost for Medicare-covered urgently-needed-care visits |
Outpatient Rehabilitation Services |
20% of the cost for Medicare-covered Occupational Therapy visits |
20% of the cost 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 |
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% 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 |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
20% of the cost for Medicare-covered Cardiac Rehabilitation Services |
20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services |
20% of the cost 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 |
Cost plan members pay Fee-for-Service cost sharing for out-of-area dialysis. |
20% of the cost 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 |
In general preventive dental benefits (such as cleaning) not covered. |
20% of the cost for Medicare-covered dental benefits |
Hearing Services |
In general supplemental routine hearing exams and hearing aids not covered. |
20% of the cost for Medicare-covered diagnostic hearing exams |
** Additional Benefits ** |
Vision Services |
Non-Medicare Supplemental eye exams and glasses not covered. |
$0 copay for one pair of eyeglasses or contact lenses after cataract surgery |
0% to 20% of the cost for exams to diagnose and treat diseases and conditions of the eye. |
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. |
$0 copay |
$300 out-of-pocket limit every benefit period. |
** Outpatient Care ** |
Doctor Office Visits |
20% of the cost for each primary care doctor visit for Medicare-covered benefits. |
20% of the cost for each in-area network urgent care Medicare-covered visit |
20% of the cost for each specialist visit for Medicare-covered benefits. |
Outpatient Services/Surgery |
20% of the cost for each Medicare-covered ambulatory surgical center visit |
20% of the cost for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
20% of the cost 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% 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 |
** Additional Benefits ** |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
This plan does not cover supplemental routine transportation. |