** Cost ** |
Premium and Other Important Information |
$0 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 for Medicare-covered services. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network hospitals and specialists (for certain benefits). |
** 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 |
Authorization rules may apply. |
$0 copay for up to 12 one-way trip(s) to plan-approved location every year |
** Important Information ** |
Premium and Other Important Information |
$0 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 for Medicare-covered services. |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network hospitals and specialists (for certain benefits). |
** Inpatient Care ** |
Inpatient Hospital Care |
Plan covers 175 days each benefit period. |
$0 copay |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Inpatient Mental Health Care |
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. |
$0 copay |
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 150 days each benefit period |
No prior hospital stay is required. |
$0 copay for SNF services |
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 |
Authorization rules may apply. |
$0 copay for each Medicare-covered primary care doctor visit. |
$0 copay for each Medicare-covered specialist visit. |
Chiropractic Services |
Authorization rules may apply. |
$0 copay for Medicare-covered chiropractic visits |
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. |
$0 copay for Medicare-covered podiatry visits |
up to 6 supplemental routine podiatry visit(s) every year |
Medicare-covered podiatry visits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$0 copay for: |
- each Medicare-covered individual therapy visit
|
each Medicare-covered group therapy visit |
$0 copay for: |
- each Medicare-covered individual therapy visit with a psychiatrist
|
each Medicare-covered group therapy visit with a psychiatrist |
$0 copay for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$0 copay for: |
- each Medicare-covered individual substance abuse outpatient treatment visit
|
each Medicare-covered group substance abuse outpatient treatment visit |
Outpatient Services |
Authorization rules may apply. |
$0 copay for each Medicare-covered ambulatory surgical center visit |
$0 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
Authorization rules may apply. |
$100 copay for Medicare-covered ambulance benefits. |
Emergency Care |
$65 copay for Medicare-covered emergency room visits |
$10 000 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 |
$0 copay for Medicare-covered urgently-needed-care visits |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
$0 copay for Medicare-covered Occupational Therapy visits |
$0 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. |
0% to 20% of the cost for Medicare-covered durable medical equipment |
Prosthetic Devices |
Authorization rules may apply. |
$0 copay for Medicare-covered prosthetic devices |
Diabetes Programs and Supplies |
Authorization rules may apply. |
$0 copay for Medicare-covered Diabetes self-management training |
$0 copay for Medicare-covered: |
- Diabetes monitoring supplies
|
Therapeutic shoes or inserts |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
$0 copay for Medicare-covered: |
|
diagnostic procedures and tests |
X-rays |
$0 to $75 copay for Medicare-covered diagnostic radiology services (not including X-rays) |
$60 copay for Medicare-covered therapeutic radiology services |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
Authorization rules may apply. |
$0 copay for: |
- Medicare-covered Cardiac Rehabilitation Services
|
Medicare-covered Intensive Cardiac Rehabilitation Services |
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. |
Authorization rules may apply. |
The plan covers the following supplemental education/wellness programs: |
- Additional Smoking and Tobacco Use Cessation Visits
|
$0 copay for Incontinence Care Program. Contact plan for details. |
Kidney Disease and Conditions |
Authorization rules may apply. |
$0 copay for Medicare-covered renal dialysis |
$0 copay for Medicare-covered kidney disease education services |
Outpatient Prescription Drugs |
0% to 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. |
$0 copay for home infusion drugs that would normally be covered under Part D. This cost-sharing amount will also cover the supplies and services associated with home infusion of these drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.caremore.com 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. |
Some drugs have quantity limits. |
Your provider must get prior authorization from CareMore Touch (HMO SNP) 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. |
If you request a formulary exception for a drug and CareMore Touch (HMO SNP) approves the exception you will pay Tier 4: Non-Preferred Brand cost sharing for that drug. |
$0 deductible. |
You pay the following: |
Tier 1: Preferred Generic |
Tier 2: Non-Preferred Generic |
Tier 3: Preferred Brand |
Tier 4: Non-Preferred Brand |
Tier 5: Specialty Tier |
Tier 6: Select Care Drugs |
- $0 copay for a one-month (30-day) supply of drugs in this tier
|
$5 copay for a one-month (30-day) supply of drugs in this tier |
$25 copay for a one-month (30-day) supply of drugs in this tier |
$85 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 |
$0 copay for a one-month (30-day) supply of drugs in this tier |
$0 copay for a three-month (90-day) supply of drugs in this tier |
$15 copay for a three-month (90-day) supply of drugs in this tier |
$75 copay for a three-month (90-day) supply of drugs in this tier |
$255 copay for a three-month (90-day) supply of drugs in this tier |
$0 copay for a three-month (90-day) supply of drugs in this tier |
Tier 1: Preferred Generic |
Tier 2: Non-Preferred Generic |
Tier 3: Preferred Brand |
Tier 4: Non-Preferred Brand |
Tier 5: Specialty Tier |
Tier 6: Select Care Drugs |
- $0 copay for a one-month (31-day) supply of drugs in this tier
|
$5 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 |
$25 copay for a one-month (31-day) supply of drugs in this tier |
$85 copay for a one-month (31-day) supply of drugs in this tier |
$0 copay for a one-month (31-day) supply of drugs in this tier |
Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed. |
Tier 1: Preferred Generic |
Tier 2: Non-Preferred Generic |
Tier 3: Preferred Brand |
Tier 4: Non-Preferred Brand |
Tier 5: Specialty Tier |
Tier 6: Select Care Drugs |
- 33% coinsurance for a one-month (30-day) supply of drugs in this tier
|
$0 copay for a three-month (90-day) supply of drugs in this tier |
$12.50 copay for a three-month (90-day) supply of drugs in this tier |
$62.50 copay for a three-month (90-day) supply of drugs in this tier |
$212.50 copay for a three-month (90-day) supply of drugs in this tier |
$0 copay for a three-month (90-day) supply of drugs in this tier |
Tier 1: Preferred Generic |
Tier 2: Non-Preferred Generic |
Tier 3: Preferred Brand |
Tier 4: Non-Preferred Brand |
Tier 5: Specialty Tier |
Tier 6: Select Care Drugs |
After your yearly out-of-pocket drug costs reach $4 750 you pay the following: |
- $0 copay for drugs in this tier
|
$2.65 copay [or 5% coinsurance] [whichever costs more] for drugs in this tier |
$6.60 copay [or 5% coinsurance] [whichever costs more] for drugs in this tier |
$6.60 copay [or 5% coinsurance] [whichever costs more] for drugs in this tier |
$6.60 copay [or 5% coinsurance] [whichever costs more] for drugs in this tier |
$0 copay for drugs in this tier |
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 CareMore Touch (HMO SNP). |
You pay the following: |
Tier 1: Preferred Generic |
Tier 2: Non-Preferred Generic |
Tier 3: Preferred Brand |
Tier 4: Non-Preferred Brand |
Tier 5: Specialty Tier |
Tier 6: Select Care Drugs |
- $0 copay for a one-month (30-day) supply of drugs in this tier
|
$5 copay for a one-month (30-day) supply of drugs in this tier |
$25 copay for a one-month (30-day) supply of drugs in this tier |
$85 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 |
$0 copay 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 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 $4 750 you will be reimbursed for drugs purchased out-of-network up to the plan’s cost of the drug minus the following: |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount. |
Tier 1: Preferred Generic |
Tier 2: Non-Preferred Generic |
Tier 3: Preferred Brand |
Tier 4: Non-Preferred Brand |
Tier 5: Specialty Tier |
Tier 6: Select Care Drugs |
- $0 copay for drugs in this tier
|
$2.65 copay [or 5% coinsurance] [whichever costs more] for drugs in this tier |
$6.60 copay [or 5% coinsurance] [whichever costs more] for drugs in this tier |
$6.60 copay [or 5% coinsurance] [whichever costs more] for drugs in this tier |
$6.60 copay [or 5% coinsurance] [whichever costs more] for drugs in this tier |
$0 copay for drugs in this tier |
Dental Services |
Authorization rules may apply. |
$0 copay for Medicare-covered dental benefits |
This plan covers some preventive dental benefits for an extra cost (see "Optional Supplemental Benefits.") |
Hearing Services |
$0 copay for Medicare-covered diagnostic hearing exams |
$0 copay for : |
- up to 1 supplemental routine hearing exam(s) every year
|
up to 1 fitting-evaluation(s) for a hearing aid every year |
$0 copay for hearing aids. |
$1 500 plan coverage limit for hearing aids every two years. |
** Additional Benefits ** |
Vision Services |
Authorization rules may apply. |
$0 copay for - one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery
|
- $0 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 copay for up to 1 pair(s) of contacts every year |
$20 copay for up to 1 pair(s) of lenses every year |
$0 copay for up to 1 frame(s) every two years |
$100 plan coverage limit for contact lenses every year. |
$100 plan coverage limit for eye glass frames every two years. |
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 |
Authorization rules may apply. |
$0 copay for up to 12 one-way trip(s) to plan-approved location every year |
Acupuncture |
This plan does not cover Acupuncture. |
** Inpatient Care ** |
Inpatient Hospital Care |
Plan covers 175 days each benefit period. |
$0 copay |
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 |
Authorization rules may apply. |
$0 copay for each Medicare-covered primary care doctor visit. |
$0 copay for each Medicare-covered specialist visit. |
Outpatient Services |
Authorization rules may apply. |
$0 copay for each Medicare-covered ambulatory surgical center visit |
$0 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
Authorization rules may apply. |
$100 copay for Medicare-covered ambulance benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
0% to 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 |
$0 to $75 copay for Medicare-covered diagnostic radiology services (not including X-rays) |
$60 copay for Medicare-covered therapeutic radiology 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 |
Authorization rules may apply. |
$0 copay for up to 12 one-way trip(s) to plan-approved location every year |
** Cost ** |
Premium and Other Important Information |
Package: 1 - Optional Dental: |
$8 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Preventive Dental
- Comprehensive Dental
|
** Important Information ** |
Package: 1 - Optional Dental: |
$8 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Preventive Dental
- Comprehensive Dental
|
** Preventive Services ** |
Dental Services |
Plan offers additional comprehensive dental benefits. |
- $0 to $45 copay for cleanings
|
$0 to $10 copay for fluoride treatments |
$0 copay for oral exams |
$0 copay for up to 1 dental x-ray(s) every three years |