** 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. |
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 |
$3 900 out-of-pocket limit for Medicare-covered services. |
$5 800 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. |
Plan covers you when you travel in the U.S. or its territories. |
** 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. |
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 |
$3 900 out-of-pocket limit for Medicare-covered services. |
$5 800 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. |
Plan covers you when you travel in the U.S. or its territories. |
** 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 - 5: $175 copay per day
|
Days 6 - 60: $0 copay per day |
Days 61 - 90: $100 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. |
30% of the cost for each hospital stay. |
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 - 5: $175 copay per day
|
Days 6 - 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. |
30% of the cost for each hospital stay. |
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: $50 copay per day
|
Days 21 - 100: $150 copay per day |
30% of the cost for each SNF stay. |
Home Health Care |
Authorization rules may apply. |
$0 copay for Medicare-covered home health visits |
30% of the cost 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 |
$10 copay for each Medicare-covered primary care doctor visit. |
$30 copay for each Medicare-covered specialist visit. |
$35 copay for each Medicare-covered primary care doctor visit |
$35 copay for each Medicare-covered specialist visit |
Chiropractic Services |
Authorization rules may apply. |
$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. |
$35 copay for Medicare-covered chiropractic visits. |
Podiatry Services |
Authorization rules may apply. |
$30 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 |
Authorization rules may apply. |
$30 copay for each Medicare-covered individual therapy visit |
$30 copay for each Medicare-covered group therapy visit |
$30 copay for each Medicare-covered individual therapy visit with a psychiatrist |
$30 copay for each Medicare-covered group therapy visit with a psychiatrist |
$30 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 |
30% of the cost for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$50 copay for Medicare-covered individual substance abuse outpatient treatment visits |
$50 copay for Medicare-covered group substance abuse outpatient treatment visits |
30% of the cost Medicare-covered substance abuse outpatient treatment visits |
Outpatient Services |
Authorization rules may apply. |
$75 copay for each Medicare-covered ambulatory surgical center visit |
$50 to $95 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit |
30% of the cost for Medicare-covered outpatient hospital facility visits |
30% of the cost for Medicare-covered ambulatory surgical center visits |
Ambulance Services |
Authorization rules may apply. |
$200 copay for Medicare-covered ambulance benefits. |
$200 copay for Medicare-covered ambulance benefits. |
Emergency Care |
$65 copay for Medicare-covered emergency room visits |
Worldwide coverage. |
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 |
$35 copay for Medicare-covered urgently-needed-care visits |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
$50 copay for Medicare-covered Occupational Therapy visits |
$50 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits |
$35 copay [or 30% of the cost] for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits |
$35 copay [or 30% of the cost] for Medicare-covered Occupational Therapy visits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
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. |
30% of the cost for Medicare-covered durable medical equipment |
Prosthetic Devices |
Authorization rules may apply. |
20% of the cost for Medicare-covered prosthetic devices |
30% 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 |
0% to 20% of the cost for Medicare-covered Diabetes monitoring supplies |
0% of the cost for Medicare-covered Therapeutic shoes or inserts |
$35 copay [or 30% of the cost] for Medicare-covered Diabetes self-management training |
30% of the cost for Medicare-covered Diabetes monitoring supplies |
30% of the cost for Medicare-covered Therapeutic shoes or inserts |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
$0 to $50 copay for Medicare-covered lab services |
$0 to $50 copay for Medicare-covered diagnostic procedures and tests |
$10 to $50 copay for Medicare-covered X-rays |
$10 to $50 copay for Medicare-covered diagnostic radiology services (not including X-rays) |
$30 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 |
$35 copay [or 30% of the cost] for Medicare-covered outpatient X-rays |
$35 copay [or 30% of the cost] for Medicare-covered diagnostic radiology services |
$35 copay [or 30% of the cost] for Medicare-covered diagnostic procedures tests and lab services |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
Authorization rules may apply. |
$30 to $50 copay for Medicare-covered Cardiac Rehabilitation Services |
$30 to $50 copay for Medicare-covered Intensive Cardiac Rehabilitation Services |
$30 to $50 copay for Medicare-covered Pulmonary Rehabilitation Services |
$35 copay [or 30% of the cost] for Medicare-covered Cardiac Rehabilitation Services |
$35 copay [or 30% of the cost] for Medicare-covered Intensive Cardiac Rehabilitation Services |
$35 copay [or 30% 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 |
Health Club Membership/Fitness Classes |
Nursing Hotline |
$0 to $35 copay [or 30% of the cost] for Medicare-covered preventive services |
$35 copay for an annual physical exam |
50% of the cost for supplemental education/wellness programs |
Kidney Disease and Conditions |
Authorization rules may apply. |
0% to 20% of the cost for Medicare-covered renal dialysis |
$0 copay for Medicare-covered kidney disease education services |
$35 copay for Medicare-covered kidney disease education services |
0% to 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 |
Authorization rules may apply. |
$0 copay for the following preventive dental benefits: |
- up to 2 oral exam(s) every year
|
up to 2 cleaning(s) every year |
up to 1 dental x-ray(s) every year |
$30 copay for Medicare-covered dental benefits |
$35 copay for Medicare-covered comprehensive dental benefits |
50% of the cost for supplemental comprehensive dental benefits |
50% of the cost for supplemental preventive dental benefits |
Contact the plan for availability of additional in-network and out-of-network comprehensive dental benefits. |
Hearing Services |
Authorization rules may apply. |
$0 copay for up to 1 hearing aid(s) every three years |
$30 copay for Medicare-covered diagnostic hearing exams |
$0 copay for up to 1 supplemental routine hearing exam(s) every year |
$0 copay for up to 1 hearing aid fitting-evaluation(s) every year |
$35 copay for Medicare-covered diagnostic hearing exams. |
25% of the cost for supplemental hearing exams. |
25% of the cost for supplemental hearing aids. |
$1 000 plan coverage limit for supplemental routine hearing aids every three years. This limit applies to both in-network and out-of-network benefits. |
** Additional Benefits ** |
Vision Services |
Authorization rules may apply. |
$0 copay for - one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery
|
- $0 to $30 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 |
$35 copay for Medicare-covered eye exams |
$0 copay for supplemental eye exams |
$0 copay for Medicare-covered eye wear |
$40 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 |
No limit to the number of days covered by the plan each hospital stay. |
For Medicare-covered hospital stays: |
- Days 1 - 5: $175 copay per day
|
Days 6 - 60: $0 copay per day |
Days 61 - 90: $100 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. |
30% of the cost for each hospital stay. |
** Outpatient Care ** |
Doctor Office Visits |
$10 copay for each Medicare-covered primary care doctor visit. |
$30 copay for each Medicare-covered specialist visit. |
$35 copay for each Medicare-covered primary care doctor visit |
$35 copay for each Medicare-covered specialist visit |
Outpatient Services |
Authorization rules may apply. |
$75 copay for each Medicare-covered ambulatory surgical center visit |
$50 to $95 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit |
30% of the cost for Medicare-covered outpatient hospital facility visits |
30% of the cost for Medicare-covered ambulatory surgical center visits |
Ambulance Services |
Authorization rules may apply. |
$200 copay for Medicare-covered ambulance benefits. |
$200 copay 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 |
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. |
30% of the cost for Medicare-covered durable medical equipment |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
$0 to $50 copay for Medicare-covered lab services |
$0 to $50 copay for Medicare-covered diagnostic procedures and tests |
$10 to $50 copay for Medicare-covered X-rays |
$10 to $50 copay for Medicare-covered diagnostic radiology services (not including X-rays) |
$30 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 |
$35 copay [or 30% of the cost] for Medicare-covered outpatient X-rays |
$35 copay [or 30% of the cost] for Medicare-covered diagnostic radiology services |
$35 copay [or 30% 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 Vision: |
$10 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: |
** Important Information ** |
Package: 1 - MyOption Vision: |
$10 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: |
** Additional Benefits ** |
Vision Services |
- $0 copay for up to 1 pair(s) of contacts every year
|
$0 copay for up to 1 pair(s) of glasses every year |
$0 copay for up to 1 supplemental routine eye exam(s) every year |