** 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 does not have a deductible. |
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. |
Your yearly limit(s) in this plan: |
- $3 400 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 |
Not covered |
** 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: 20% of the cost |
Other Part B drugs1: 20% of the cost |
You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Preferred Retail Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | $0 | Tier 2 (Non-Preferred Generic) | $7.50 copay | $22.50 copay | Tier 3 (Preferred Brand) | $40 copay | $120 copay | Tier 4 (Non-Preferred Brand) | $85 copay | $255 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Tier 6 (Select Care Drugs) | $0 | $0 |
|
Standard Retail Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $5 copay | $15 copay | Tier 2 (Non-Preferred Generic) | $12.50 copay | $37.50 copay | Tier 3 (Preferred Brand) | $45 copay | $135 copay | Tier 4 (Non-Preferred Brand) | $95 copay | $285 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Tier 6 (Select Care Drugs) | $0 | $0 |
|
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 | $18.75 copay | Tier 3 (Preferred Brand) | Not Offered | $100 copay | Tier 4 (Non-Preferred Brand) | Not Offered | $212.50 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Tier 6 (Select Care Drugs) | Not Offered | $0 |
|
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.
|
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap. |
Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
|
Preferred Retail Cost-SharingTier | Drugs Covered | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | $0 | $0 | Tier 2 (Non-Preferred Generic) | All | $7.50 copay | $22.50 copay | Tier 6 (Select Care Drugs) | Some | $0 | $0 |
|
Standard Retail Cost-SharingTier | Drugs Covered | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | $5 copay | $15 copay | Tier 2 (Non-Preferred Generic) | All | $12.50 copay | $37.50 copay | Tier 6 (Select Care Drugs) | Some | $0 | $0 |
|
Standard Mail Order Cost-SharingTier | Drugs Covered | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | Not Offered | $0 | Tier 2 (Non-Preferred Generic) | All | Not Offered | $18.75 copay | Tier 6 (Select Care Drugs) | Some | Not Offered | $0 |
|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the following: |
Tier | Your cost |
---|
Tier 1 (Preferred Generic) | $0 | Tier 2 (Non-Preferred Generic) | $2.65 copay or 5% of the cost (whichever costs more) | Tier 3 (Preferred Brand) | $6.60 copay or 5% of the cost (whichever costs more) | Tier 4 (Non-Preferred Brand) | $6.60 copay or 5% of the cost (whichever costs more) | Tier 5 (Specialty Tier) | $6.60 copay or 5% of the cost (whichever costs more) | Tier 6 (Select Care Drugs) | $6.60 copay or 5% of the cost (whichever costs more) |
|
** 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 does not have a deductible. |
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. |
Your yearly limit(s) in this plan: |
- $3 400 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 |
Not covered |
Ambulance Services |
$195 copay |
Chiropractic Care |
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay |
Dental Services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): $0-30 copay depending on the service |
Diabetes Supplies and Services |
Diabetes monitoring supplies: 20% of the cost |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: $50 copay |
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans): $0-100 copay depending on the service |
Diagnostic tests and procedures: You pay nothing |
Lab services: You pay nothing |
Outpatient x-rays: You pay nothing |
Therapeutic radiology services (such as radiation treatment for cancer): 20% of the cost |
Doctor’s Office Visits |
Primary care physician visit: You pay nothing |
Specialist visit: $0-30 copay depending on the service |
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
0-20% of the cost depending on the equipment |
Emergency Care |
$65 copay |
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: $0-30 copay depending on the service |
Routine foot care (for up to 4 visit(s) every year): $0-30 copay depending on the service |
Hearing Services |
Exam to diagnose and treat hearing and balance issues: You pay nothing |
Routine hearing exam (for up to 1 every year): You pay nothing |
Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing |
Home Health Care |
You pay nothing |
Mental Health Care |
Inpatient visit: |
Our plan covers 150 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 150 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 150 days. |
|
$200 copay per day for days 1 through 5 |
You pay nothing per day for days 6 through 90 |
You pay nothing per day for days 91 through 150 |
|
Outpatient group therapy visit: $0-30 copay depending on the service |
Outpatient individual therapy visit: $0-30 copay depending on the service |
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): $25 copay |
Occupational therapy visit: $20 copay |
Physical therapy and speech and language therapy visit: $0-20 copay depending on the service |
Outpatient Substance Abuse |
Group therapy visit: $30 copay |
Individual therapy visit: $30 copay |
Outpatient Surgery |
Ambulatory surgical center: $100 copay |
Outpatient hospital: $200 copay |
Over-the-Counter Items |
Not Covered |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: 0-20% of the cost depending on the device |
Related medical supplies: 0-20% of the cost depending on the supply |
Renal Dialysis |
20% of the cost |
Transportation |
You pay nothing |
Urgently Needed Care |
$20 copay |
Vision Services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-30 copay depending on the service |
Routine eye exam (for up to 1 every year): You pay nothing |
Contact lenses (for up to 1 every two years): You pay nothing |
Our plan pays up to $100 every two years for contact lenses. |
Eyeglasses frames (for up to 1 every two years): You pay nothing |
Our plan pays up to $100 every two years for eyeglass frames. |
Eyeglasses lenses (for up to 1 every two years): $20 copay |
Eyeglasses or contact lenses after cataract surgery: You pay nothing |
** 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. |
** Inpatient Care ** |
Inpatient Hospital Care |
Our plan covers 280 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 280 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 280 days. |
|
$200 copay per day for days 1 through 5 |
You pay nothing per day for days 6 through 90 |
You pay nothing per day for days 91 through 280 |
|
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. |
|
You pay nothing per day for days 1 through 20 |
$125 copay per day for days 21 through 100 |
|
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs1: 20% of the cost |
Other Part B drugs1: 20% of the cost |
You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Preferred Retail Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | $0 | Tier 2 (Non-Preferred Generic) | $7.50 copay | $22.50 copay | Tier 3 (Preferred Brand) | $40 copay | $120 copay | Tier 4 (Non-Preferred Brand) | $85 copay | $255 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Tier 6 (Select Care Drugs) | $0 | $0 |
|
Standard Retail Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $5 copay | $15 copay | Tier 2 (Non-Preferred Generic) | $12.50 copay | $37.50 copay | Tier 3 (Preferred Brand) | $45 copay | $135 copay | Tier 4 (Non-Preferred Brand) | $95 copay | $285 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Tier 6 (Select Care Drugs) | $0 | $0 |
|
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 | $18.75 copay | Tier 3 (Preferred Brand) | Not Offered | $100 copay | Tier 4 (Non-Preferred Brand) | Not Offered | $212.50 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Tier 6 (Select Care Drugs) | Not Offered | $0 |
|
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.
|
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap. |
Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
|
Preferred Retail Cost-SharingTier | Drugs Covered | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | $0 | $0 | Tier 2 (Non-Preferred Generic) | All | $7.50 copay | $22.50 copay | Tier 6 (Select Care Drugs) | Some | $0 | $0 |
|
Standard Retail Cost-SharingTier | Drugs Covered | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | $5 copay | $15 copay | Tier 2 (Non-Preferred Generic) | All | $12.50 copay | $37.50 copay | Tier 6 (Select Care Drugs) | Some | $0 | $0 |
|
Standard Mail Order Cost-SharingTier | Drugs Covered | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | Not Offered | $0 | Tier 2 (Non-Preferred Generic) | All | Not Offered | $18.75 copay | Tier 6 (Select Care Drugs) | Some | Not Offered | $0 |
|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the following: |
Tier | Your cost |
---|
Tier 1 (Preferred Generic) | $0 | Tier 2 (Non-Preferred Generic) | $2.65 copay or 5% of the cost (whichever costs more) | Tier 3 (Preferred Brand) | $6.60 copay or 5% of the cost (whichever costs more) | Tier 4 (Non-Preferred Brand) | $6.60 copay or 5% of the cost (whichever costs more) | Tier 5 (Specialty Tier) | $6.60 copay or 5% of the cost (whichever costs more) | Tier 6 (Select Care Drugs) | $6.60 copay or 5% of the cost (whichever costs more) |
|
** Outpatient Care ** |
Diabetes Supplies and Services |
Diabetes monitoring supplies: 20% of the cost |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: $50 copay |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $0-30 copay depending on the service |
Routine foot care (for up to 4 visit(s) every year): $0-30 copay depending on the service |
Hearing Services |
Exam to diagnose and treat hearing and balance issues: You pay nothing |
Routine hearing exam (for up to 1 every year): You pay nothing |
Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing |
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit: $30 copay |
Individual therapy visit: $30 copay |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: 0-20% of the cost depending on the device |
Related medical supplies: 0-20% of the cost depending on the supply |
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |