** 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. |
This plan does not allow providers to balance bill (charging more than your cost share amount). |
$6 000 out-of-pocket limit for Medicare-covered services. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You may go to any doctor specialist or hospital that accepts the plan’s terms and conditions of payment. |
** 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. |
This plan does not allow providers to balance bill (charging more than your cost share amount). |
$6 000 out-of-pocket limit for Medicare-covered services. |
Doctor and Hospital Choice |
You may go to any doctor specialist or hospital that accepts the plan’s terms and conditions of payment. |
** Inpatient Care ** |
Inpatient Hospital Care |
You may go to any doctor or hospital that accepts the plan’s terms and conditions of payment. In emergencies you may go to any doctor or hospital even those that do not participate with the plan. |
No limit to the number of days covered by the plan each hospital stay. |
For Medicare-covered hospital stays: |
- Days 1 - 7: $225 copay per day
|
Days 8 - 90: $0 copay per day |
$0 copay for each additional hospital day. |
For hospital stays: |
- Days 1 - 7: $225 copay per day
|
Days 8 - 90: $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 - 7: $205 copay per day
|
Days 8 - 90: $0 copay per day |
For hospital stays: |
- Days 1 - 7: $205 copay per day
|
Days 8 - 90: $0 copay per day |
Skilled Nursing Facility (SNF) |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
For SNF stays: |
- Days 1 - 14: $0 copay per day
|
Days 15 - 21: $50 copay per day |
Days 22 - 100: $125 copay per day |
For each SNF stay: |
- Days 1 - 14: $0 copay per SNF day
|
Days 15 - 21: $50 copay per SNF day |
Days 22 - 100: $125 copay per SNF day |
Home Health Care |
$0 copay for Medicare-covered home health visits |
$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 |
You may go to any doctor that accepts the plan’s terms and conditions of payment. |
$15 copay for each Medicare-covered primary care doctor visit. |
$35 copay for each Medicare-covered specialist visit. |
$15 copay for each Medicare-covered primary care doctor visit |
$35 copay for each Medicare-covered specialist visit |
Chiropractic Services |
$20 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. |
$20 copay for Medicare-covered chiropractic visits. |
Podiatry Services |
$35 copay for each Medicare-covered podiatry visit |
Medicare-covered podiatry visits are for medically-necessary foot care. |
$35 copay for Medicare-covered podiatry visits |
Outpatient Mental Health Care |
$35 copay for each Medicare-covered individual therapy visit |
$35 copay for each Medicare-covered group therapy visit |
$35 copay for each Medicare-covered individual therapy visit with a psychiatrist |
$35 copay for each Medicare-covered group therapy visit with a psychiatrist |
$35 copay for Medicare-covered partial hospitalization program services |
$35 copay for Medicare-covered Mental Health visits with a psychiatrist |
$35 copay for Medicare-covered Mental Health visits |
$35 copay for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
25% of the cost for Medicare-covered individual substance abuse outpatient treatment visits |
25% of the cost for Medicare-covered group substance abuse outpatient treatment visits |
25% of the cost Medicare-covered substance abuse outpatient treatment visits |
Outpatient Services |
20% of the cost for each Medicare-covered ambulatory surgical center visit |
20% to 25% of the cost for each Medicare-covered outpatient hospital facility visit |
20% to 25% of the cost for Medicare-covered outpatient hospital facility visits |
20% of the cost for Medicare-covered ambulatory surgical center visits |
Ambulance Services |
20% of the cost for Medicare-covered ambulance benefits. |
20% of the cost for Medicare-covered ambulance benefits. |
Emergency Care |
$65 copay for Medicare-covered emergency room visits |
$25 000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. |
Urgently Needed Care |
$15 to $35 copay for Medicare-covered urgently-needed-care visits |
Outpatient Rehabilitation Services |
There may be limits on physical therapy occupational therapy and speech and language pathology visits. If so there may be exceptions to these limits. |
$35 copay [or 25% of the cost] for Medicare-covered Occupational Therapy visits |
$35 copay [or 25% of the cost] for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits |
$35 copay [or 20% to 25% of the cost] for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits |
$35 copay [or 20% to 25% of the cost] for Medicare-covered Occupational Therapy visits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
20% of the cost for Medicare-covered durable medical equipment |
You may pay less if you purchase these items from the plan’s preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors. |
20% of the cost for Medicare-covered durable medical equipment |
Prosthetic Devices |
20% 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% to 20% of the cost for Medicare-covered Diabetes monitoring supplies |
$10 copay 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 |
$0 to $35 copay [or 25% of the cost] for Medicare-covered lab services |
$0 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic procedures and tests |
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered X-rays |
$175 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) |
$35 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services |
$35 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services |
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered outpatient X-rays |
$175 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic radiology services |
$0 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic procedures tests and lab services |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
$35 copay [or 25% of the cost] for Medicare-covered Cardiac Rehabilitation Services |
$35 copay [or 25% of the cost] for Medicare-covered Intensive Cardiac Rehabilitation Services |
$35 copay [or 25% of the cost] for Medicare-covered Pulmonary Rehabilitation Services |
$35 copay [or 20% to 25% of the cost] for Medicare-covered Cardiac Rehabilitation Services |
$35 copay [or 20% to 25% of the cost] for Medicare-covered Intensive Cardiac Rehabilitation Services |
$35 copay [or 20% to 25% 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. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. |
$0 copay for an annual physical exam |
The plan covers the following supplemental education/wellness programs: |
|
Additional Smoking and Tobacco Use Cessation Visits |
Nursing Hotline |
$0 copay for Medicare-covered preventive services |
$0 copay for an annual physical exam |
50% of the cost for supplemental education/wellness programs |
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 |
20% of the cost for Medicare Part B drugs out-of-network. |
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. |
$35 copay for Medicare-covered dental benefits |
$35 copay for Medicare-covered comprehensive dental benefits |
Hearing Services |
In general supplemental routine hearing exams and hearing aids not covered. |
$35 copay for Medicare-covered diagnostic hearing exams |
$35 copay for Medicare-covered diagnostic hearing exams. |
** Additional Benefits ** |
Vision Services |
- $25 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.
|
$0 to $35 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye. |
$0 copay for up to 1 supplemental routine eye exam(s) every year |
$0 to $35 copay for Medicare-covered eye exams |
$0 copay for supplemental eye exams |
$25 copay for Medicare-covered eye wear |
$130 plan coverage limit for supplemental routine eye exams every year. This limit applies to both in-network and out-of-network 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. |
Acupuncture |
This plan does not cover Acupuncture. |
** Inpatient Care ** |
Inpatient Hospital Care |
You may go to any doctor or hospital that accepts the plan’s terms and conditions of payment. In emergencies you may go to any doctor or hospital even those that do not participate with the plan. |
No limit to the number of days covered by the plan each hospital stay. |
For Medicare-covered hospital stays: |
- Days 1 - 7: $225 copay per day
|
Days 8 - 90: $0 copay per day |
$0 copay for each additional hospital day. |
For hospital stays: |
- Days 1 - 7: $225 copay per day
|
Days 8 - 90: $0 copay per day |
** Outpatient Care ** |
Doctor Office Visits |
You may go to any doctor that accepts the plan’s terms and conditions of payment. |
$15 copay for each Medicare-covered primary care doctor visit. |
$35 copay for each Medicare-covered specialist visit. |
$15 copay for each Medicare-covered primary care doctor visit |
$35 copay for each Medicare-covered specialist visit |
Outpatient Services |
20% of the cost for each Medicare-covered ambulatory surgical center visit |
20% to 25% of the cost for each Medicare-covered outpatient hospital facility visit |
20% to 25% of the cost for Medicare-covered outpatient hospital facility visits |
20% of the cost for Medicare-covered ambulatory surgical center visits |
Ambulance Services |
20% of the cost for Medicare-covered ambulance benefits. |
20% of the cost for Medicare-covered ambulance benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
20% of the cost for Medicare-covered durable medical equipment |
You may pay less if you purchase these items from the plan’s preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors. |
20% of the cost for Medicare-covered durable medical equipment |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
$0 to $35 copay [or 25% of the cost] for Medicare-covered lab services |
$0 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic procedures and tests |
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered X-rays |
$175 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) |
$35 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services |
$35 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services |
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered outpatient X-rays |
$175 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic radiology services |
$0 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic procedures tests and lab 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. |
** Cost ** |
Premium and Other Important Information |
Package: 1 - MyOption Fitness Well-being: |
$32 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Supplemental Education/Wellness Programs
|
** Important Information ** |
Package: 1 - MyOption Fitness Well-being: |
$32 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Supplemental Education/Wellness Programs
|