** Cost ** |
Premium and Other Important Information |
$139.6 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. |
$3 400 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. |
No referral required for network doctors specialists and hospitals. |
** 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 |
$139.6 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. |
$3 400 out-of-pocket limit. All plan services included. |
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. |
$500 copay for each Medicare-covered hospital stay |
$0 copay for additional hospital days |
Inpatient Mental Health Care |
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. |
$500 copay for each Medicare-covered hospital stay. |
$0 copay for additional hospital days |
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 - 20: 10% of the cost per day |
Days 21 - 100: 0% of the cost 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 |
$20 copay for each primary care doctor visit for Medicare-covered benefits. |
$20 copay for each in-area network urgent care Medicare-covered visit |
$20 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
$15 copay for each Medicare-covered visit |
$15 copay for each supplemental routine 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 copay for each Medicare-covered visit |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
$20 copay for each Medicare-covered individual therapy visit |
$20 copay for each Medicare-covered group therapy visit |
$20 copay for each Medicare-covered individual therapy visit with a psychiatrist |
$20 copay for each Medicare-covered group therapy visit with a psychiatrist |
$0 copay for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
$20 copay for Medicare-covered individual visits |
$20 copay for Medicare-covered group visits |
Outpatient Services/Surgery |
$0 copay for each Medicare-covered ambulatory surgical center visit |
$0 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
$0 copay for Medicare-covered ambulance benefits. |
Emergency Care |
$0 to $50 copay for Medicare-covered emergency room visits |
Worldwide coverage. |
If you are admitted to the hospital within 3-day(s) for the same condition you pay $0 for the emergency room visit. |
Urgently Needed Care |
$20 copay for Medicare-covered urgently-needed-care visits |
Outpatient Rehabilitation Services |
$20 copay for Medicare-covered Occupational Therapy visits |
$20 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 |
$0 copay for Diabetes self-management training |
5% to 25% of the cost for Diabetes monitoring supplies |
10% 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 $20 may apply |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
$0 copay for Medicare-covered: |
lab services |
diagnostic procedures and tests |
X-rays |
diagnostic radiology services (not including X-rays) |
therapeutic radiology services |
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $20 may apply |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $20 may apply |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
$10 copay for Medicare-covered Cardiac Rehabilitation Services |
$10 copay for Medicare-covered Intensive Cardiac Rehabilitation Services |
$10 copay for Medicare-covered Pulmonary Rehabilitation Services |
$10 copay for additional Cardiac Rehabilitation Services |
$10 copay for additional Intensive Cardiac Rehabilitation Services |
$10 copay for additional Pulmonary Rehabilitation Services |
No limit on the number of additional Cardiac Rehabilitation Services |
No limit on the number of additional Intensive Cardiac Rehabilitation Services |
No limit on the number of additional 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 |
20% of the cost for renal dialysis |
$0 copay for kidney disease education services |
Outpatient Prescription Drugs |
$0 copay for Part B-covered drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.glhealthplan.org/spformulary 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 Gundersen Lutheran Senior Pref. Elite (w/RX) (HMO) 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. |
You pay $0 the first time you fill a prescription for certain drugs. These drugs will be listed as 'free first fill' on the plan?s website formulary printed materials and on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If you request a formulary exception for a drug and Gundersen Lutheran Senior Pref. Elite (w/RX) (HMO) approves the exception you will pay Tier 4: Non-Preferred Brand Drugs cost sharing for that drug. |
$0 deductible. |
You pay the following until total yearly drug costs reach $2 930: |
Tier 1: Preferred Generic Drugs |
Tier 2: Non-Preferred Generic Drugs |
Tier 3: Preferred Brand Drugs |
Tier 4: Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$9 copay for a one-month (30-day) supply of drugs in this tier |
$33 copay for a one-month (30-day) supply of drugs in this tier |
$44 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 |
33% coinsurance for a one-month (30-day) supply of drugs in this tier |
$27 copay for a three-month (90-day) supply of drugs in this tier |
$99 copay for a three-month (90-day) supply of drugs in this tier |
$132 copay for a three-month (90-day) supply of drugs in this tier |
$285 copay for a three-month (90-day) supply of drugs in this tier |
33% coinsurance for a three-month (90-day) supply of drugs in this tier |
Tier 1: Preferred Generic Drugs |
Tier 2: Non-Preferred Generic Drugs |
Tier 3: Preferred Brand Drugs |
Tier 4: Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$9 copay for a one-month (31-day) supply of drugs in this tier |
$33 copay for a one-month (31-day) supply of drugs in this tier |
$44 copay for a one-month (31-day) supply of drugs in this tier |
$95 copay for a one-month (31-day) supply of drugs in this tier |
33% coinsurance for a one-month (31-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 Gundersen Lutheran Senior Pref. Elite (w/RX) (HMO). |
You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 930: |
Tier 1: Preferred Generic Drugs |
Tier 2: Non-Preferred Generic Drugs |
Tier 3: Preferred Brand Drugs |
Tier 4: Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$9 copay for a one-month (30-day) supply of drugs in this tier |
$33 copay for a one-month (30-day) supply of drugs in this tier |
$44 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 |
33% coinsurance for a one-month (30-day) supply of drugs in this tier |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
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. |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
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. |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
Dental Services |
In general preventive dental benefits (such as cleaning) not covered. |
$20 copay for Medicare-covered dental benefits |
Hearing Services |
Hearing aids not covered. |
$0 copay for Medicare-covered diagnostic hearing exams |
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 |
glasses |
lenses |
frames |
$0 to $20 copay for exams to diagnose and treat diseases and conditions of the eye. |
$0 to $20 copay for supplemental routine eye exams |
$300 plan coverage limit for eye wear every year. |
Plan offers additional vision benefits. Contact plan for details. |
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. |
$500 copay for each Medicare-covered hospital stay |
$0 copay for additional hospital days |
** Outpatient Care ** |
Doctor Office Visits |
$20 copay for each primary care doctor visit for Medicare-covered benefits. |
$20 copay for each in-area network urgent care Medicare-covered visit |
$20 copay for each specialist visit for Medicare-covered benefits. |
Outpatient Services/Surgery |
$0 copay for each Medicare-covered ambulatory surgical center visit |
$0 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
$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' |
$0 copay for Medicare-covered: |
lab services |
diagnostic procedures and tests |
X-rays |
diagnostic radiology services (not including X-rays) |
therapeutic radiology services |
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $20 may apply |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $20 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. |