** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$145.5 per month. In addition you must keep paying your Medicare Part B premium. |
This plan does not have a deductible. |
Yes. 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. |
No. There are no limits on how much our plan will pay. |
** 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: You pay nothing |
Other Part B drugs1: You pay nothing |
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. |
Standard Retail Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $4 copay | $8 copay | $12 copay | Tier 2 (Non-Preferred Generic) | $15 copay | $30 copay | $45 copay | Tier 3 (Preferred Brand) | $45 copay | $90 copay | $135 copay | Tier 4 (Non-Preferred Brand) | $85 copay | $170 copay | $255 copay | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost |
|
Standard Mail Order Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $4 copay | $8 copay | $8 copay | Tier 2 (Non-Preferred Generic) | $15 copay | $30 copay | $30 copay | Tier 3 (Preferred Brand) | $45 copay | $90 copay | $90 copay | Tier 4 (Non-Preferred Brand) | $85 copay | $170 copay | $170 copay | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost |
|
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. |
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 greater of: - $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
|
** Important Information ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$145.5 per month. In addition you must keep paying your Medicare Part B premium. |
This plan does not have a deductible. |
Yes. 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. |
No. There are no limits on how much our plan will pay. |
** Outpatient Care and Services ** |
Acupuncture and Other Alternative Therapies |
Not covered |
Ambulance Services |
$75 copay |
If you are admitted to the hospital you do not have to pay for the ambulance services. |
Chiropractic Care |
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $15 copay |
Dental Services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing |
Diabetes Supplies and Services |
Diabetes monitoring supplies: 20% of the cost |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: 20% of the cost |
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans): $0-15 copay depending on the service |
Diagnostic tests and procedures: $0-15 copay depending on the service |
Lab services: $0-15 copay depending on the service |
Outpatient x-rays: $0-15 copay depending on the service |
Therapeutic radiology services (such as radiation treatment for cancer): $0-15 copay depending on the service |
Doctor’s Office Visits |
Primary care physician visit: $15 copay |
Specialist visit: $15 copay |
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
20% of the cost |
Emergency Care |
$200 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: $15 copay |
Hearing Services |
Exam to diagnose and treat hearing and balance issues: $15 copay |
Routine hearing exam (for up to 1 every year): $15 copay |
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. |
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. |
|
$450 copay per stay |
|
Outpatient group therapy visit: $15 copay |
Outpatient individual therapy visit: $15 copay |
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): $15 copay |
Occupational therapy visit: $15 copay |
Physical therapy and speech and language therapy visit: $15 copay |
Outpatient Substance Abuse |
Group therapy visit: $15 copay |
Individual therapy visit: $15 copay |
Outpatient Surgery |
Ambulatory surgical center: $100 copay |
Outpatient hospital: $15 copay |
Over-the-Counter Items |
Not Covered |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: 20% of the cost |
Related medical supplies: 20% of the cost |
Renal Dialysis |
$15 copay |
Transportation |
Not covered |
Urgently Needed Care |
$40 copay |
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): $15 copay |
Routine eye exam (for up to 1 every year): $15 copay |
Eyeglasses (frames and lenses) (for up to 1 every two years): $15 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 an unlimited number of days for an inpatient hospital stay. |
|
$450 copay per stay |
You pay nothing per day for days 91 and beyond |
|
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 |
$35 copay per day for days 21 through 100 |
|
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs1: You pay nothing |
Other Part B drugs1: You pay nothing |
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. |
Standard Retail Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $4 copay | $8 copay | $12 copay | Tier 2 (Non-Preferred Generic) | $15 copay | $30 copay | $45 copay | Tier 3 (Preferred Brand) | $45 copay | $90 copay | $135 copay | Tier 4 (Non-Preferred Brand) | $85 copay | $170 copay | $255 copay | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost |
|
Standard Mail Order Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $4 copay | $8 copay | $8 copay | Tier 2 (Non-Preferred Generic) | $15 copay | $30 copay | $30 copay | Tier 3 (Preferred Brand) | $45 copay | $90 copay | $90 copay | Tier 4 (Non-Preferred Brand) | $85 copay | $170 copay | $170 copay | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost |
|
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. |
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 greater of: - $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
|
** Outpatient Care ** |
Diabetes Supplies and Services |
Diabetes monitoring supplies: 20% of the cost |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: 20% of the cost |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $15 copay |
Hearing Services |
Exam to diagnose and treat hearing and balance issues: $15 copay |
Routine hearing exam (for up to 1 every year): $15 copay |
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit: $15 copay |
Individual therapy visit: $15 copay |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: 20% of the cost |
Related medical supplies: 20% of the cost |
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |
** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
Package 1: Dental Services |
Benefits include:- Preventive Dental
- Comprehensive Dental
|
Additional $12 per month. You must keep paying your Medicare Part B premium and your $145.50 monthly plan premium. |
This package does not have a deductible. |
Our plan pays up to $1000 every year. |
** Important Information ** |
Package 1: Dental Services |
Benefits include:- Preventive Dental
- Comprehensive Dental
|
Additional $12 per month. You must keep paying your Medicare Part B premium and your $145.50 monthly plan premium. |
This package does not have a deductible. |
Our plan pays up to $1000 every year. |