** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$77 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
$1 500 per year for out-of-network services. |
This plan does not have a deductible for Part D prescription drugs. |
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.
|
- $3 500 for services you receive from out-of-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 drugs:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Other Part B drugs:- In-network: 0-20% of the cost depending on the drug
|
- Out-of-network: 20% of the cost after you pay your deductible
|
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) | $6 copay | $12 copay | $18 copay | Tier 2 (Non-Preferred Generic) | $19 copay | $38 copay | $57 copay | Tier 3 (Preferred Brand) | $45 copay | $90 copay | $135 copay | Tier 4 (Non-Preferred Brand) | $95 copay | $190 copay | $285 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | Tier 6 (Vaccines) | $0 | Not Offered | Not Offered |
|
Standard Mail Order Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $6 copay | $12 copay | $18 copay | Tier 2 (Non-Preferred Generic) | $19 copay | $38 copay | $57 copay | Tier 3 (Preferred Brand) | $45 copay | $90 copay | $135 copay | Tier 4 (Non-Preferred Brand) | $95 copay | $190 copay | $285 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered |
|
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.
|
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 |
$77 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
$1 500 per year for out-of-network services. |
This plan does not have a deductible for Part D prescription drugs. |
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.
|
- $3 500 for services you receive from out-of-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 |
|
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% of the cost after you pay your deductible
|
Routine chiropractic visit: |
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
|
Diabetes Supplies and Services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans): |
- Out-of-network: 20% of the cost after you pay your deductible
|
Diagnostic tests and procedures:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Lab services:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Outpatient x-rays:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: You pay nothing
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Doctor’s Office Visits |
Primary care physician visit: |
- Out-of-network: 20% of the cost after you pay your deductible
|
Specialist visit: |
- Out-of-network: 20% of the cost after you pay your deductible
|
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost after you pay your deductible
|
If you go to a preferred vendor your cost may be less. Contact us for a list of preferred vendors. |
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: 20% of the cost after you pay your deductible
|
Hearing Services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: 20% of the cost after you pay your deductible
|
Routine hearing exam:- In-network: $50 copay. You are covered for up to 1 every year.
|
- Out-of-network: 20% of the cost after you pay your deductible. There may be a limit to how often these services are covered.
|
Home Health Care |
- In-network: You pay nothing
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Mental Health Care |
Inpatient visit: |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
|
In-network: |
$300 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 and beyond |
|
|
Out-of-network: |
$1 500 deductible for inpatient hospital and mental health care |
20% of the cost per stay |
|
Outpatient group therapy visit: |
- Out-of-network: 20% of the cost after you pay your deductible
|
Outpatient individual therapy visit: |
- Out-of-network: 20% of the cost after you pay your deductible
|
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: You pay nothing
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Occupational therapy visit: |
- Out-of-network: 20% of the cost after you pay your deductible
|
Physical therapy and speech and language therapy visit: |
- Out-of-network: 20% of the cost after you pay your deductible
|
Outpatient Substance Abuse |
Group therapy visit:- In-network: $0-50 copay depending on the service
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Individual therapy visit:- In-network: $0-50 copay depending on the service
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Outpatient Surgery |
Ambulatory surgical center:- In-network: $0-150 copay depending on the service
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Outpatient hospital:- In-network: $0-400 copay depending on the service
|
- Out-of-network: 20% of the cost after you pay your deductible
|
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 after you pay your deductible
|
Related medical supplies:- In-network: 0-20% of the cost depending on the supply
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Renal Dialysis |
- In-network: You pay nothing
|
Transportation |
Not covered |
Urgently Needed Care |
$20-50 copay depending on the service |
Vision Services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):- In-network: $0-50 copay depending on the service
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Routine eye exam:- In-network: $0-50 copay depending on the service
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Eyeglasses or contact lenses after cataract surgery:- In-network: 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 |
- 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: |
$300 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 and beyond |
|
|
Out-of-network: |
$1 500 deductible for inpatient hospital and mental health care |
20% of the cost 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 6
|
- $40 copay per day for days 7 through 45
|
- $0 copay per day for days 46 through 100
|
|
|
Out-of-network: |
$1 500 deductible |
20% of the cost per stay |
|
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Other Part B drugs:- In-network: 0-20% of the cost depending on the drug
|
- Out-of-network: 20% of the cost after you pay your deductible
|
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) | $6 copay | $12 copay | $18 copay | Tier 2 (Non-Preferred Generic) | $19 copay | $38 copay | $57 copay | Tier 3 (Preferred Brand) | $45 copay | $90 copay | $135 copay | Tier 4 (Non-Preferred Brand) | $95 copay | $190 copay | $285 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | Tier 6 (Vaccines) | $0 | Not Offered | Not Offered |
|
Standard Mail Order Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $6 copay | $12 copay | $18 copay | Tier 2 (Non-Preferred Generic) | $19 copay | $38 copay | $57 copay | Tier 3 (Preferred Brand) | $45 copay | $90 copay | $135 copay | Tier 4 (Non-Preferred Brand) | $95 copay | $190 copay | $285 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered |
|
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.
|
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:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: |
- Out-of-network: 20% of the cost after you pay your deductible
|
Hearing Services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: 20% of the cost after you pay your deductible
|
Routine hearing exam:- In-network: $50 copay. You are covered for up to 1 every year.
|
- Out-of-network: 20% of the cost after you pay your deductible. There may be a limit to how often these services are covered.
|
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit:- In-network: $0-50 copay depending on the service
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Individual therapy visit:- In-network: $0-50 copay depending on the service
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost after you pay your deductible
|
Related medical supplies:- In-network: 0-20% of the cost depending on the supply
|
- Out-of-network: 20% of the cost after you pay your deductible
|
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |