** Cost ** |
Premium and Other Important Information |
$45.00 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. |
Some physicians providers and suppliers that are out of a plan’s network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment " your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare "limiting charge" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.go |
$2 500 out-of-pocket limit for Medicare-covered services. |
$125 annual deductible. Contact the plan for services that apply. |
Any annual service category deductible may count towards the plan level deductible if there is one. |
$5 100 out-of-pocket limit for Medicare-covered services. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network 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 |
$45.00 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. |
Some physicians providers and suppliers that are out of a plan’s network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment " your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare "limiting charge" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.go |
$2 500 out-of-pocket limit for Medicare-covered services. |
$125 annual deductible. Contact the plan for services that apply. |
Any annual service category deductible may count towards the plan level deductible if there is one. |
$5 100 out-of-pocket limit for Medicare-covered services. |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network 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 - 8: $175 copay per day
|
Days 9 - 90: $0 copay per day |
$0 copay for each additional hospital day. |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
For hospital stays: |
- Days 1 - 8: $200 copay per day
|
Days 9 and beyond: $0 copay per day |
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 - 8: $175 copay per day
|
Days 9 - 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. |
For hospital stays: |
- Days 1 - 8: $200 copay per day
|
Days 9 - 190: $0 copay per day |
Skilled Nursing Facility (SNF) |
Authorization rules may apply. |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
For Medicare-covered SNF stays: |
- Days 1 - 20: $0 copay per day
|
Days 21 - 100: $100 copay per day |
For each SNF stay: |
- Days 1 - 20: $0 copay per SNF day
|
Days 21 - 100: $150 copay per SNF day |
Home Health Care |
Authorization rules may apply. |
$0 copay for each Medicare-covered home health visit |
$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 |
$12 copay for each Medicare-covered primary care doctor visit. |
$12 copay for each Medicare-covered specialist visit. |
$20 copay for each Medicare-covered primary care doctor visit |
$20 copay for each Medicare-covered specialist visit |
Chiropractic Services |
Authorization rules may apply. |
$15 copay for each Medicare-covered chiropractic visit |
$15 copay for each supplemental routine 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. |
$15 copay for Medicare-covered chiropractic visits. |
$15 copay for supplemental routine chiropractic visits. |
Podiatry Services |
$12 copay for each Medicare-covered podiatry visit |
Medicare-covered podiatry visits are for medically-necessary foot care. |
$20 copay for Medicare-covered podiatry visits |
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 |
$0 copay for Medicare-covered partial hospitalization program services |
$50 copay for Medicare-covered Mental Health visits with a psychiatrist |
$50 copay for Medicare-covered Mental Health visits |
$0 copay for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
$25 copay for Medicare-covered individual substance abuse outpatient treatment visits |
$25 copay for Medicare-covered group substance abuse outpatient treatment visits |
$50 copay Medicare-covered substance abuse outpatient treatment visits |
Outpatient Services |
Authorization rules may apply. |
$150 copay for each Medicare-covered ambulatory surgical center visit |
$175 copay for each Medicare-covered outpatient hospital facility visit |
$200 copay for Medicare-covered outpatient hospital facility visits |
$175 copay for Medicare-covered ambulatory surgical center visits |
Ambulance Services |
$100 copay for Medicare-covered ambulance benefits. |
$100 copay for Medicare-covered ambulance benefits. |
Emergency Care |
$65 copay for Medicare-covered emergency room visits |
$50 000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. |
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 |
$12 to $50 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. |
$25 copay for Medicare-covered Occupational Therapy visits |
$25 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits |
$35 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits |
$35 copay for Medicare-covered Occupational Therapy visits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
15% of the cost for Medicare-covered durable medical equipment |
20% of the cost for Medicare-covered durable medical equipment |
Prosthetic Devices |
Authorization rules may apply. |
15% of the cost for Medicare-covered prosthetic devices |
20% of the cost for Medicare-covered prosthetic devices. |
Diabetes Programs and Supplies |
$0 copay for Medicare-covered Diabetes self-management training |
$0 copay for Medicare-covered Diabetes monitoring supplies |
15% of the cost for Medicare-covered Therapeutic shoes or inserts |
$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 |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
$0 copay for Medicare-covered lab services |
0% to 15% of the cost for Medicare-covered diagnostic procedures and tests |
$12 copay for Medicare-covered X-rays |
15% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) |
15% 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 $12 may apply |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $12 may apply |
20% of the cost for Medicare-covered therapeutic radiology services |
$20 copay for Medicare-covered outpatient X-rays |
20% of the cost for Medicare-covered diagnostic radiology services |
0% to 20% of the cost for Medicare-covered diagnostic procedures tests and lab services |
If the doctor provides you services in addition to (Outpatient X-Rays) separate cost sharing of $20 may apply |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
$25 copay for Medicare-covered Cardiac Rehabilitation Services |
$25 copay for Medicare-covered Intensive Cardiac Rehabilitation Services |
$25 copay for Medicare-covered Pulmonary Rehabilitation Services |
$35 copay for Medicare-covered Cardiac Rehabilitation Services |
$35 copay for Medicare-covered Intensive Cardiac Rehabilitation Services |
$35 copay 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. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. |
The plan covers the following supplemental education/wellness programs: |
|
Additional Smoking and Tobacco Use Cessation Visits |
Health Club Membership/Fitness Classes |
Nursing Hotline |
$0 copay for Additional Pap Smears/Additional Pelvic Exams. Contact plan for details. |
$0 copay for Medicare-covered preventive services |
$0 copay for supplemental education/wellness programs |
$0 copay for Additional Pap Smears/Additional Pelvic Exams |
Kidney Disease and Conditions |
20% of the cost for Medicare-covered renal dialysis |
$0 copay for Medicare-covered kidney disease education services |
$0 copay for Medicare-covered kidney disease education services |
20% of the cost for Medicare-covered renal dialysis |
Outpatient Prescription Drugs |
Most drugs not covered. |
15% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. |
20% of the cost for Medicare Part B drugs out-of-network. |
This plan does not offer prescription drug coverage. |
Dental Services |
This plan covers some preventive dental benefits for an extra cost (see "Optional Supplemental Benefits.") |
$12 to $65 copay for Medicare-covered dental benefits |
$20 to $65 copay for Medicare-covered comprehensive dental benefits |
Hearing Services |
In general supplemental routine hearing exams and hearing aids not covered. |
$12 copay for Medicare-covered diagnostic hearing exams |
$20 copay for Medicare-covered diagnostic hearing exams. |
** Additional Benefits ** |
Vision Services |
- $0 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.
|
$0 to $12 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye. |
$10 copay for up to 1 supplemental routine eye exam(s) every year |
$0 copay for up to 1 pair(s) of glasses every two years |
$0 copay for up to 1 pair(s) of contacts every two years |
$0 copay for up to 1 pair(s) of lenses every two years |
$0 copay for up to 1 frame(s) every two years |
$0 to $20 copay for Medicare-covered eye exams |
$0 to $20 copay for supplemental eye exams |
$0 copay for Medicare-covered eye wear |
$0 copay for supplemental eye wear |
$100 plan coverage limit for eye wear every two years. This limit applies to both in-network and out-of-network benefits. |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
This plan does not cover supplemental routine transportation. |
Acupuncture |
Authorization rules may apply. |
$15 copay per acupuncture visit |
$15 copay for acupuncture visits |
** 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 - 8: $175 copay per day
|
Days 9 - 90: $0 copay per day |
$0 copay for each additional hospital day. |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
For hospital stays: |
- Days 1 - 8: $200 copay per day
|
Days 9 and beyond: $0 copay per day |
** Outpatient Care ** |
Doctor Office Visits |
$12 copay for each Medicare-covered primary care doctor visit. |
$12 copay for each Medicare-covered specialist visit. |
$20 copay for each Medicare-covered primary care doctor visit |
$20 copay for each Medicare-covered specialist visit |
Outpatient Services |
Authorization rules may apply. |
$150 copay for each Medicare-covered ambulatory surgical center visit |
$175 copay for each Medicare-covered outpatient hospital facility visit |
$200 copay for Medicare-covered outpatient hospital facility visits |
$175 copay for Medicare-covered ambulatory surgical center visits |
Ambulance Services |
$100 copay for Medicare-covered ambulance benefits. |
$100 copay for Medicare-covered ambulance benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
15% of the cost for Medicare-covered durable medical equipment |
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 lab services |
0% to 15% of the cost for Medicare-covered diagnostic procedures and tests |
$12 copay for Medicare-covered X-rays |
15% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) |
15% 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 $12 may apply |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $12 may apply |
20% of the cost for Medicare-covered therapeutic radiology services |
$20 copay for Medicare-covered outpatient X-rays |
20% of the cost for Medicare-covered diagnostic radiology services |
0% to 20% of the cost for Medicare-covered diagnostic procedures tests and lab services |
If the doctor provides you services in addition to (Outpatient X-Rays) 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. |
** Cost ** |
Premium and Other Important Information |
Package: 1 - Preventive Dental Plus: |
$31 monthly premium in addition to your $45 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Preventive Dental
- Comprehensive Dental
|
$1 250 plan coverage limit every year for these benefits. |
** Important Information ** |
Package: 1 - Preventive Dental Plus: |
$31 monthly premium in addition to your $45 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Preventive Dental
- Comprehensive Dental
|
$1 250 plan coverage limit every year for these benefits. |
** Preventive Services ** |
Dental Services |
- $0 copay for up to 2 cleaning(s) every year
|
$0 copay for up to 2 oral exam(s) every year |
$0 copay for up to 1 dental x-ray(s) every year |
20% of the cost for preventive dental services |
20% to 50% of the cost for comprehensive dental services |
Contact the plan for availability of additional in-network and out-of-network comprehensive dental benefits. |
$1 250 plan coverage limit for dental benefits every year. This limit applies to both in-network and out-of-network benefits. |