** Cost ** |
Premium and Other Important Information |
$55.00 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 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. |
$3 400 out-of-pocket limit for select Medicare-covered services. Contact plan for details regarding Medicare-covered services under this limit. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
Referral required for network hospitals and specialists (for certain benefits). |
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. |
** 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 |
$55.00 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 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. |
$3 400 out-of-pocket limit for select Medicare-covered services. Contact plan for details regarding Medicare-covered services under this limit. |
Doctor and Hospital Choice |
Referral required for network hospitals and specialists (for certain benefits). |
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. |
** Inpatient Care ** |
Inpatient Hospital Care |
Plan covers 90 days each benefit period. |
$450 copay for each Medicare-covered hospital stay |
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day. |
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. |
$450 copay for each Medicare-covered hospital stay. |
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 |
For Medicare-covered SNF stays: |
- Days 1 - 20: $0 copay per day
|
Days 21 - 100: $75 copay per day |
Home Health Care |
Authorization rules may apply. |
$15 copay for each Medicare-covered home health visit |
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 |
$15 copay for each Medicare-covered primary care doctor visit. |
$30 copay for each Medicare-covered specialist visit. |
Chiropractic Services |
$10 copay for each Medicare-covered chiropractic 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. |
Podiatry Services |
Authorization rules may apply. |
$30 copay for each Medicare-covered podiatry visit |
Medicare-covered podiatry visits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$25 copay for each Medicare-covered individual therapy visit |
$25 copay for each Medicare-covered group therapy visit |
$25 copay for each Medicare-covered individual therapy visit with a psychiatrist |
$25 copay for each Medicare-covered group therapy visit with a psychiatrist |
$300 copay for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$25 copay for Medicare-covered individual substance abuse outpatient treatment visits |
$25 copay for Medicare-covered group substance abuse outpatient treatment visits |
Outpatient Services |
Authorization rules may apply. |
$200 copay for each Medicare-covered ambulatory surgical center visit |
$200 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
Authorization rules may apply. |
$100 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 |
Not covered outside the U.S. and its territories except under limited circumstances. Contact plan for 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 |
$30 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 |
Authorization rules may apply. |
$20 copay for Medicare-covered Occupational Therapy visits |
$20 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
20% of the cost for Medicare-covered durable medical equipment |
Prosthetic Devices |
Authorization rules may apply. |
20% of the cost for Medicare-covered prosthetic devices |
Diabetes Programs and Supplies |
Authorization rules may apply. |
$0 copay for Medicare-covered Diabetes self-management training |
20% of the cost for Medicare-covered Diabetes monitoring supplies |
20% of the cost for Medicare-covered Therapeutic shoes or inserts |
If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $15 to $30 may apply |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
$0 copay for Medicare-covered: |
|
diagnostic procedures and tests |
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 |
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $15 to $30 may apply |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $15 to $30 may apply |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
Authorization rules may apply. |
$20 copay for Medicare-covered Cardiac Rehabilitation Services |
$20 copay for Medicare-covered Intensive Cardiac Rehabilitation Services |
$20 copay for Medicare-covered Pulmonary Rehabilitation Services |
Preventive Services and Wellness/Education Programs |
Authorization rules may apply. |
$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. |
This plan does not cover supplemental education/wellness programs. |
Kidney Disease and Conditions |
Authorization rules may apply. |
Cost plan members pay Original Medicare cost sharing for out-of-area dialysis. |
20% of the cost for Medicare-covered renal dialysis |
$0 copay for Medicare-covered kidney disease education services |
Outpatient Prescription Drugs |
Most drugs not covered. |
20% of the cost for Medicare Part B chemotherapy drugs and other Part B 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. |
$25 copay for Medicare-covered diagnostic hearing exams |
** Additional Benefits ** |
Vision Services |
This plan offers only Medicare-covered eye care and eye wear |
$0 copay for - one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery
|
- $25 copay for Medicare-covered 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 |
Plan covers 90 days each benefit period. |
$450 copay for each Medicare-covered hospital stay |
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day. |
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 |
$15 copay for each Medicare-covered primary care doctor visit. |
$30 copay for each Medicare-covered specialist visit. |
Outpatient Services |
Authorization rules may apply. |
$200 copay for each Medicare-covered ambulatory surgical center visit |
$200 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
Authorization rules may apply. |
$100 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 durable medical equipment |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
$0 copay for Medicare-covered: |
|
diagnostic procedures and tests |
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 |
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $15 to $30 may apply |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $15 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. |