** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$138.00 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: |
- $4 000 for services you receive from in-network providers.
|
- $6 000 for services you receive from any provider.
|
Your limit for services received from in-network providers will count toward this limit. |
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 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: |
- Out-of-network: 20% of the cost
|
Other Part B drugs1:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Our plan does not cover Part D prescription drug. |
** Important Information ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$138.00 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: |
- $4 000 for services you receive from in-network providers.
|
- $6 000 for services you receive from any provider.
|
Your limit for services received from in-network providers will count toward this limit. |
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 in-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: $200 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
|
Dental Services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Preventive dental services: |
Cleaning (for up to 2 every year):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Dental x-ray(s) (for up to 2 every year):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Fluoride treatment (for up to 2 every year):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Oral exam (for up to 2 every year):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Our plan pays up to $250 every year for preventive dental services from any provider. |
Diabetes Supplies and Services |
Diabetes monitoring supplies:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Therapeutic shoes or inserts:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans): |
- Out-of-network: $60 copay
|
Diagnostic tests and procedures:- In-network: You pay nothing
|
- Out-of-network: $50 copay
|
Lab services:- In-network: You pay nothing
|
- Out-of-network: $50 copay
|
Outpatient x-rays: |
- Out-of-network: $60 copay
|
Therapeutic radiology services (such as radiation treatment for cancer): |
- Out-of-network: $60 copay
|
Doctor’s Office Visits |
Primary care physician visit: |
- Out-of-network: $40 copay
|
Specialist visit: |
- Out-of-network: $50 copay
|
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
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: |
- Out-of-network: $50 copay
|
Hearing Services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: $50 copay
|
Routine hearing exam (for up to 1 every year): |
- Out-of-network: $50 copay
|
Home Health Care |
- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Mental Health Care |
Inpatient visit: |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
|
In-network: |
$600 copay per stay |
You pay nothing per day for days 91 and beyond |
|
|
Out-of-network: |
$1 200 copay per stay |
|
Outpatient group therapy visit: |
- Out-of-network: $40 copay
|
Outpatient individual therapy visit: |
- Out-of-network: $40 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): |
- Out-of-network: $10 copay
|
Occupational therapy visit: |
- Out-of-network: $40 copay
|
Physical therapy and speech and language therapy visit: |
- Out-of-network: $40 copay
|
Outpatient Substance Abuse |
Group therapy visit: |
- Out-of-network: $40 copay
|
Individual therapy visit: |
- Out-of-network: $40 copay
|
Outpatient Surgery |
Ambulatory surgical center: |
- Out-of-network: $175 copay
|
Outpatient hospital: |
- Out-of-network: $225 copay
|
Over-the-Counter Items |
Not Covered |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Renal Dialysis |
|
- Out-of-network: $30 copay
|
Transportation |
- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Urgently Needed Care |
$35 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): |
- Out-of-network: $0-50 copay depending on the service
|
Routine eye exam (for up to 1 every year):- In-network: $0-30 copay depending on the service
|
- Out-of-network: $0-50 copay depending on the service
|
Contact lenses:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglasses (frames and lenses):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglass frames:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglass lenses:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglasses or contact lenses after cataract surgery:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Our plan pays up to $100 every year for eyewear from any provider. |
** 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: 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. |
|
In-network: |
$600 copay per stay |
You pay nothing per day for days 91 and beyond |
|
|
Out-of-network: |
$1 200 copay per stay |
|
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: |
- $0 copay per day for days 1 through 20
|
- $90 copay per day for days 21 through 100
|
|
|
Out-of-network: |
You pay nothing per day for days 1 through 20 |
$150 copay per day for days 21 through 100 |
|
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs1: |
- Out-of-network: 20% of the cost
|
Other Part B drugs1:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
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% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Therapeutic shoes or inserts:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: |
- Out-of-network: $50 copay
|
Hearing Services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: $50 copay
|
Routine hearing exam (for up to 1 every year): |
- Out-of-network: $50 copay
|
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit: |
- Out-of-network: $40 copay
|
Individual therapy visit: |
- Out-of-network: $40 copay
|
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |