** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$0 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
This plan does not have a deductible for Part D prescription drugs. |
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. |
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility. Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document. |
Your yearly limit(s) in this plan: |
- $6 700 for services you receive from in-network providers.
|
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. |
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. |
** Doctor and Hospital Choice ** |
Acupuncture and Other Alternative Therapies |
You pay nothing |
** Extra Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs1: 0% or 20% of the cost |
Other Part B drugs1: 0% or 20% of the cost |
Our plan does not have a deductible for Part D prescription drugs. |
You pay the following:
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Standard Retail Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | $0 | Tier 2 (Non-Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Not Offered |
|
Standard Mail Order Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | Not Offered | $0 | Tier 2 (Non-Preferred Generic) | Not Offered | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Preferred Brand) | Not Offered | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 4 (Non-Preferred Brand) | Not Offered | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Not Offered |
|
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
|
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay nothing for all drugs. |
** Important Information ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$0 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
This plan does not have a deductible for Part D prescription drugs. |
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. |
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility. Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document. |
Your yearly limit(s) in this plan: |
- $6 700 for services you receive from in-network providers.
|
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. |
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. |
** Outpatient Care and Services ** |
Acupuncture and Other Alternative Therapies |
You pay nothing |
Ambulance Services |
0% or 20% of the cost |
Chiropractic Care |
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 0% or 20% of the cost |
Dental Services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): 0% or 20% of the cost |
Preventive dental services: |
Cleaning: You pay nothing |
Dental x-ray(s): You pay nothing |
Fluoride treatment: You pay nothing |
Oral exam: You pay nothing |
Diabetes Supplies and Services |
Diabetes monitoring supplies: 0% or 20% of the cost |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: 0% or 20% of the cost |
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans): 0% or 20% of the cost |
Diagnostic tests and procedures: 0% or 20% of the cost |
Lab services: You pay nothing |
Outpatient x-rays: 0% or 20% of the cost |
Therapeutic radiology services (such as radiation treatment for cancer): 0% or 20% of the cost |
Doctor’s Office Visits |
Primary care physician visit: 0% or 20% of the cost |
Specialist visit: 0% or 20% of the cost |
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
0% or 20% of the cost |
Emergency Care |
0% or 20% of the cost |
If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs. |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: 0% or 20% of the cost |
Hearing Services |
Exam to diagnose and treat hearing and balance issues: 0% or 20% of the cost |
Routine hearing exam: You pay nothing |
Hearing aid fitting/evaluation: You pay nothing |
Hearing aid: You pay nothing |
Home Health Care |
You pay nothing |
Mental Health Care |
Inpatient visit: |
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. |
The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. |
Our plan covers 90 days for an inpatient hospital stay. |
Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days. |
Outpatient group therapy visit: 0% or 20% of the cost |
Outpatient individual therapy visit: 0% or 20% of the cost |
Outpatient Rehabilitation Services |
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): 0% or 20% of the cost |
Occupational therapy visit: 0% or 20% of the cost |
Physical therapy and speech and language therapy visit: 0% or 20% of the cost |
Outpatient Substance Abuse |
Group therapy visit: 0% or 20% of the cost |
Individual therapy visit: 0% or 20% of the cost |
Outpatient Surgery |
Ambulatory surgical center: 0% or 20% of the cost |
Outpatient hospital: 0% or 20% of the cost |
Over-the-Counter Items |
Please visit our website to see our list of covered over-the-counter items. |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: 0% or 20% of the cost |
Related medical supplies: 0% or 20% of the cost |
Renal Dialysis |
0% or 20% of the cost |
Transportation |
You pay nothing |
Urgently Needed Care |
0% or 20% of the cost |
If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgent care. See the "Inpatient Hospital Care" section for other costs. |
Vision Services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): 0% or 20% of the cost |
Routine eye exam (for up to 1 every year): You pay nothing |
Contact lenses (for up to 1 every year): You pay nothing |
Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing |
Eyeglass frames (for up to 1 every year): You pay nothing |
Eyeglass lenses (for up to 1 every year): You pay nothing |
Eyeglasses or contact lenses after cataract surgery: 0% or 20% of the cost |
** Hospice ** |
Hospice |
You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. |
** Preventive Care ** |
Preventive Care |
You pay nothing |
Our plan covers many preventive services including: - Abdominal aortic aneurysm screening
- Alcohol misuse counseling
- Bone mass measurement
- Breast cancer screening (mammogram)
- Cardiovascular disease (behavioral therapy)
- Cardiovascular screenings
- Cervical and vaginal cancer screening
- Colonoscopy
- Colorectal cancer screenings
- Depression screening
- Diabetes screenings
- Fecal occult blood test
- Flexible sigmoidoscopy
- HIV screening
- Medical nutrition therapy services
- Obesity screening and counseling
- Prostate cancer screenings (PSA)
- Sexually transmitted infections screening and counseling
- Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
- Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
- "Welcome to Medicare" preventive visit (one-time)
- Yearly "Wellness" visit
Any additional preventive services approved by Medicare during the contract year will be covered. |
Annual physical exam: You pay nothing |
** Inpatient Care ** |
Inpatient Hospital Care |
The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. |
Our plan covers 90 days for an inpatient hospital stay. |
Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days. |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |
Skilled Nursing Facility (SNF) |
Our plan covers up to 100 days in a SNF. |
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs1: 0% or 20% of the cost |
Other Part B drugs1: 0% or 20% of the cost |
Our plan does not have a deductible for Part D prescription drugs. |
You pay the following:
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Standard Retail Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | $0 | Tier 2 (Non-Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Not Offered |
|
Standard Mail Order Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | Not Offered | $0 | Tier 2 (Non-Preferred Generic) | Not Offered | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Preferred Brand) | Not Offered | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 4 (Non-Preferred Brand) | Not Offered | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Not Offered |
|
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
|
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay nothing for all drugs. |
** Outpatient Care ** |
Diabetes Supplies and Services |
Diabetes monitoring supplies: 0% or 20% of the cost |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: 0% or 20% of the cost |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: 0% or 20% of the cost |
Hearing Services |
Exam to diagnose and treat hearing and balance issues: 0% or 20% of the cost |
Routine hearing exam: You pay nothing |
Hearing aid fitting/evaluation: You pay nothing |
Hearing aid: You pay nothing |
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit: 0% or 20% of the cost |
Individual therapy visit: 0% or 20% of the cost |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: 0% or 20% of the cost |
Related medical supplies: 0% or 20% of the cost |
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |