** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$0.00 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
$500 per year for out-of-network services. |
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: |
- $6 250 for services you receive 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 monthly premiums. |
Our plan has a coverage limit every year for certain out-of-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:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the drug
|
Other Part B drugs:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the drug
|
Our plan does not cover Part D prescription drug. |
** Important Information ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$0.00 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
$500 per year for out-of-network services. |
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: |
- $6 250 for services you receive 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 monthly premiums. |
Our plan has a coverage limit every year for certain out-of-network benefits. Contact us for the services that apply. |
** Outpatient Care and Services ** |
Acupuncture and Other Alternative Therapies |
Not covered |
Ambulance Services |
|
- Out-of-network: $350 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): |
- Out-of-network: $20 copay or 30% of the cost depending on the service
|
Dental Services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): |
- Out-of-network: $40 copay or 30% of the cost depending on the service
|
Diabetes Supplies and Services |
Diabetes monitoring supplies:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the supply
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 0-30% of the cost depending on the service
|
Therapeutic shoes or inserts:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the supply
|
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans): |
- Out-of-network: $250 copay or 30% of the cost depending on the service
|
Diagnostic tests and procedures:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the service
|
Lab services:- In-network: You pay nothing
|
- Out-of-network: 0-30% of the cost depending on the service
|
Outpatient x-rays:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the service
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the service
|
Doctor’s Office Visits |
Primary care physician visit: |
- Out-of-network: $15 copay or 30% of the cost depending on the service
|
Specialist visit: |
- Out-of-network: $40 copay or 30% of the cost depending on the service
|
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the equipment
|
Emergency Care |
$65 copay |
If you are admitted to the hospital within 1 day 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: |
- Out-of-network: $20 copay or 30% of the cost depending on the service
|
Hearing Services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: $40 copay or 30% of the cost depending on the service
|
Home Health Care |
- In-network: You pay nothing
|
- Out-of-network: 0-30% of the cost depending on the service
|
Mental Health Care |
Inpatient visit: |
Our plan covers 190 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 190 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 190 days. |
|
In-network: |
$295 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 190 |
|
|
Out-of-network: |
$295 copay per day for days 1 through 5 |
You pay nothing per day for days 6 through 90 |
30% of the cost per day for days 1 through 90 |
|
Outpatient group therapy visit:- In-network: $25-40 copay depending on the service
|
- Out-of-network: $25-40 copay or 30% of the cost depending on the service
|
Outpatient individual therapy visit:- In-network: $25-40 copay depending on the service
|
- Out-of-network: $25-40 copay or 30% of the cost 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):- In-network: $25-40 copay depending on the service
|
- Out-of-network: $25-40 copay or 30% of the cost depending on the service
|
Occupational therapy visit:- In-network: $25-40 copay depending on the service
|
- Out-of-network: $25-40 copay or 30% of the cost depending on the service
|
Physical therapy and speech and language therapy visit:- In-network: $25-40 copay depending on the service
|
- Out-of-network: $25-40 copay or 30% of the cost depending on the service
|
Outpatient Substance Abuse |
Group therapy visit:- In-network: $25-40 copay depending on the service
|
- Out-of-network: $25-40 copay or 30% of the cost depending on the service
|
Individual therapy visit:- In-network: $25-40 copay depending on the service
|
- Out-of-network: $25-40 copay or 30% of the cost depending on the service
|
Outpatient Surgery |
Ambulatory surgical center:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the service
|
Outpatient hospital:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the service
|
Over-the-Counter Items |
Not Covered |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the device
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the supply
|
Renal Dialysis |
- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the service
|
Transportation |
Not covered |
Urgently Needed Care |
$15-40 copay depending on the service |
Vision Services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):- In-network: $0-40 copay depending on the service
|
- Out-of-network: $0-40 copay or 30% of the cost depending on the service
|
Routine eye exam:- In-network: You pay nothing. You are covered for up to 1 every year.
|
- Out-of-network: $0-40 copay or 30% of the cost depending on the service. There may be a limit to how often these services are covered.
|
Eyeglasses or contact lenses after cataract surgery: |
- Out-of-network: $40 copay or 30% of the cost depending on the service
|
** 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 |
- In-network: You pay nothing
|
- Out-of-network: 0-30% of the cost depending on the service
|
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 an unlimited number of days for an inpatient hospital stay. |
|
In-network: |
$275 copay per day for days 1 through 6 |
You pay nothing per day for days 7 through 90 |
You pay nothing per day for days 91 and beyond |
|
|
Out-of-network: |
$275 copay per day for days 1 through 6 |
You pay nothing per day for days 7 through 90 |
30% of the cost per day for days 1 through 90 |
|
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. |
|
In-network: |
You pay nothing per day for days 1 through 20 |
$156.50 copay per day for days 21 through 100 |
|
|
Out-of-network: |
30% of the cost per stay |
You pay nothing per day for days 1 through 20 |
$156.50 copay per day for days 21 through 100 |
|
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the drug
|
Other Part B drugs:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the drug
|
Our plan does not cover Part D prescription drug. |
** Outpatient Care ** |
Diabetes Supplies and Services |
Diabetes monitoring supplies:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the supply
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 0-30% of the cost depending on the service
|
Therapeutic shoes or inserts:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the supply
|
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: |
- Out-of-network: $20 copay or 30% of the cost depending on the service
|
Hearing Services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: $40 copay or 30% of the cost depending on the service
|
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit:- In-network: $25-40 copay depending on the service
|
- Out-of-network: $25-40 copay or 30% of the cost depending on the service
|
Individual therapy visit:- In-network: $25-40 copay depending on the service
|
- Out-of-network: $25-40 copay or 30% of the cost depending on the service
|
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the device
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 20-30% of the cost depending on the supply
|
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |