** Cost ** |
Premium and Other Important Information |
$187.00 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. |
$3 000 out-of-pocket limit. All plan services included. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
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. |
Plan covers you when you travel in the U.S. or its territories. |
** 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 |
$187.00 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. |
$3 000 out-of-pocket limit. All plan services included. |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
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. |
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. |
$150 copay for each Medicare-covered hospital stay |
$0 copay for additional hospital days |
Inpatient Mental Health Care |
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. |
$150 copay for each Medicare-covered hospital stay. |
$0 copay for additional hospital days |
Skilled Nursing Facility (SNF) |
Plan covers up to 100 days each benefit period |
$0 copay for SNF services |
Home Health Care |
$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 |
$15 copay for each Medicare-covered primary care doctor visit. |
$15 copay for each Medicare-covered specialist visit. |
Chiropractic Services |
$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. |
Podiatry Services |
$15 copay for each Medicare-covered podiatry visit |
$15 copay for each supplemental routine podiatry visit |
Medicare-covered podiatry visits are for medically-necessary foot care. |
Outpatient Mental Health Care |
$15 copay for each Medicare-covered individual therapy visit |
$7.50 copay for each Medicare-covered group therapy visit |
$15 copay for each Medicare-covered individual therapy visit with a psychiatrist |
$7.50 copay for each Medicare-covered group therapy visit with a psychiatrist |
$0 copay for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
$15 copay for Medicare-covered individual substance abuse outpatient treatment visits |
$15 copay for Medicare-covered group substance abuse outpatient treatment visits |
Outpatient Services |
$0 copay for each Medicare-covered ambulatory surgical center visit |
$0 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
10% of the cost 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 |
$15 copay for Medicare-covered urgently-needed-care visits |
Outpatient Rehabilitation Services |
$15 copay for Medicare-covered Occupational Therapy visits |
$15 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
20% of the cost for Medicare-covered durable medical equipment |
Prosthetic Devices |
20% of the cost for Medicare-covered prosthetic devices |
Diabetes Programs and Supplies |
$0 copay for Medicare-covered Diabetes self-management training |
20% of the cost for Medicare-covered Diabetes monitoring supplies |
Diabetic Supplies and Services are limited to specific manufacturers products and/or brands. Contact the plan for a list of covered supplies. |
20% of the cost for Medicare-covered Therapeutic shoes or inserts |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
$0 copay for Medicare-covered: |
|
diagnostic procedures and tests |
X-rays |
therapeutic radiology services |
10% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
$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 |
$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
|
Nursing Hotline |
$0 copay for Web and Telephone-Based Technologies. Contact plan for details. |
Kidney Disease and Conditions |
Cost plan members pay Original Medicare cost sharing for out-of-area dialysis. |
$0 copay for Medicare-covered renal dialysis |
$0 copay for Medicare-covered kidney disease education services |
Outpatient Prescription Drugs |
Most drugs not covered. |
0% to 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 |
$0 copay for Medicare-covered dental benefits |
In general preventive dental benefits (such as cleaning) not covered. |
Hearing Services |
Hearing aids not covered. |
$0 copay for: |
- up to 1 supplemental routine hearing exam(s) every year
|
$15 copay for Medicare-covered diagnostic hearing exams |
** Additional Benefits ** |
Vision Services |
$0 copay for up to 1 supplemental routine eye exam(s) every year |
$0 copay for - one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery
|
- $0 to $15 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 |
No limit to the number of days covered by the plan each hospital stay. |
$150 copay for each Medicare-covered hospital stay |
$0 copay for additional hospital days |
** Outpatient Care ** |
Doctor Office Visits |
$15 copay for each Medicare-covered primary care doctor visit. |
$15 copay for each Medicare-covered specialist visit. |
Outpatient Services |
$0 copay for each Medicare-covered ambulatory surgical center visit |
$0 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
10% 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 |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
$0 copay for Medicare-covered: |
|
diagnostic procedures and tests |
X-rays |
therapeutic radiology services |
10% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) |
** Additional Benefits ** |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
This plan does not cover supplemental routine transportation. |