** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
Some services may require a monthly payment amount. |
You pay nothing |
No. This plan does not have any limits. |
In this plan you will pay nothing for services from any provider. |
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 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 drugs: You pay nothing |
Other Part B drugs: You pay nothing |
You may get your drugs at network retail pharmacies and mail order pharmacies. |
You pay the following: |
Standard Retail Cost-SharingTier | Your cost |
---|
Tier 1 (Generic Drugs) | 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 2 (Brand Drugs) | 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 (Non-Medicare Rx Drugs) | $0 | Tier 4 (Non-Medicare OTC Drugs) | $0 |
|
Standard Mail Order Cost-SharingTier | Your cost |
---|
Tier 1 (Generic Drugs) | 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 2 (Brand Drugs) | 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 (Non-Medicare Rx Drugs) | $0 | Tier 4 (Non-Medicare OTC Drugs) | $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 at the same cost as an in-network pharmacy.
|
You pay nothing |
Institutional Care |
Case management (long term care): You pay nothing |
Nursing home services: You pay nothing |
** Important Information ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
Some services may require a monthly payment amount. |
You pay nothing |
No. This plan does not have any limits. |
In this plan you will pay nothing for services from any provider. |
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 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 |
Additional Home Care Services |
Personal care services: You pay nothing |
Self-directed personal assistance services: You pay nothing |
Additional Services |
Case management: You pay nothing |
Respite Care Services (for up to 480 hours every year): You pay nothing |
Adult Day Health Care: You pay nothing |
Personal Emergency Response System/Medication Monitoring System: You pay nothing |
Transition Services: You pay nothing (there is a limit to how much our plan will pay) |
Additional Skilled Nursing Facility Days: You pay nothing |
Community Mental Health Rehabilitative Services: You pay nothing |
Additional Outpatient Mental Health Services: You pay nothing |
Telemedicine Services: You pay nothing |
HIV Testing and Treatment Counseling (Prenatal): You pay nothing |
High Risk Prenatal Services: You pay nothing |
Additional Outpatient Substance Abuse Treatment Services: You pay nothing |
Nutrition Education for Pregnant Women (for up to 3 sessions): You pay nothing |
Health Education for Pregnant Women (for up to 12 sessions): You pay nothing |
Day & Residential Treatment for Pregnant Women: You pay nothing |
Federally Qualified health Center Services/Rural Health Clinic Services: You pay nothing |
Emergency Custody Orders/Temporary Detention Orders (TDOs): You pay nothing |
Court Ordered Services: You pay nothing |
Service Facilitation: You pay nothing |
Ambulance Services |
You pay nothing |
Chiropractic Care |
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing |
Dental Services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing |
Preventive dental services: |
Cleaning (for up to 1 every year): You pay nothing |
Dental x-ray(s) (for up to 1 every year): You pay nothing |
Oral exam (for up to 1 every year): You pay nothing |
Diabetes Supplies and Services |
Diabetes monitoring supplies: You pay nothing |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: You pay nothing |
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans): You pay nothing |
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): You pay nothing |
Doctor’s Office Visits |
Primary care physician visit: You pay nothing |
Specialist visit: You pay nothing |
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
You pay nothing |
Durable Medical Equipment (non-specific e.g. outside home): You pay nothing |
Medical Supplies: You pay nothing |
Emergency Care |
You pay nothing |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing |
Routine foot care (for up to 12 visit(s) every year): You pay nothing |
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 |
Hearing aid: You pay nothing |
Our plan pays up to $1000 every three years for hearing aids. |
Home Health Care |
You pay nothing |
Additional hours of care: You pay nothing |
Home Health Aide (for up to 32 visits every year): You pay nothing. |
Caregiver Training: You pay nothing. |
Mental Health Care |
Inpatient visit: |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
You pay nothing |
Outpatient group therapy visit: You pay nothing |
Outpatient individual therapy visit: You pay nothing |
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): You pay nothing. Additional visits are covered but your cost may be more. |
Respiratory care services: You pay nothing |
Occupational therapy visit: You pay nothing |
Additional Acute and Non-Acute Occupational Therapy: You pay nothing |
Physical therapy and speech and language therapy visit: You pay nothing |
Additional Acute and Non-Acute Physical Therapy: You pay nothing |
Additional Acute and Non-Acute Speech Therapy: You pay nothing |
Outpatient Substance Abuse |
Group therapy visit: You pay nothing |
Individual therapy visit: You pay nothing |
Outpatient Surgery |
Ambulatory surgical center: You pay nothing |
Outpatient hospital: You pay nothing |
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: You pay nothing |
Related medical supplies: You pay nothing |
Prosthetics/Orthotics: You pay nothing |
Renal Dialysis |
You pay nothing |
Transportation |
You pay nothing |
Urgently Needed Care |
You pay nothing |
Vision Services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing |
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 |
Eyeglasses or contact lenses after cataract surgery: You pay nothing |
Our plan pays up to $100 every year for contact lenses and eyeglasses (frames and lenses). |
** 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. |
Family planning services: You pay nothing |
Tobacco cessation counseling for pregnant women: You pay nothing |
** Inpatient Care ** |
Inpatient Hospital Care |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
You pay nothing |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |
Institutional Care |
Case management (long term care): You pay nothing |
Nursing home services: You pay nothing |
Skilled Nursing Facility (SNF) |
Our plan covers an unlimited number of days in a SNF. |
You pay nothing |
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs: You pay nothing |
Other Part B drugs: You pay nothing |
You may get your drugs at network retail pharmacies and mail order pharmacies. |
You pay the following: |
Standard Retail Cost-SharingTier | Your cost |
---|
Tier 1 (Generic Drugs) | 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 2 (Brand Drugs) | 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 (Non-Medicare Rx Drugs) | $0 | Tier 4 (Non-Medicare OTC Drugs) | $0 |
|
Standard Mail Order Cost-SharingTier | Your cost |
---|
Tier 1 (Generic Drugs) | 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 2 (Brand Drugs) | 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 (Non-Medicare Rx Drugs) | $0 | Tier 4 (Non-Medicare OTC Drugs) | $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 at the same cost as an in-network pharmacy.
|
You pay nothing |
Additional Home Care Services |
Personal care services: You pay nothing |
Self-directed personal assistance services: You pay nothing |
** Outpatient Care ** |
Diabetes Supplies and Services |
Diabetes monitoring supplies: You pay nothing |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: You pay nothing |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing |
Routine foot care (for up to 12 visit(s) every year): You pay nothing |
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 |
Hearing aid: You pay nothing |
Our plan pays up to $1000 every three years for hearing aids. |
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit: You pay nothing |
Individual therapy visit: You pay nothing |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: You pay nothing |
Related medical supplies: You pay nothing |
Prosthetics/Orthotics: You pay nothing |
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |
Institutional Care |
Case management (long term care): You pay nothing |
Nursing home services: You pay nothing |