** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$0 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical 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: |
- $3 200 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. |
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 |
There is a limit to how much our plan will pay: $15 copay |
** 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: 15% of the cost |
Other Part B drugs1: 15% of the cost |
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. |
Preferred Retail Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $3 copay | $6 copay | $9 copay | Tier 2 (Non-Preferred Generic) | $8 copay | $16 copay | $24 copay | Tier 3 (Preferred Brand) | $35 copay | $70 copay | $105 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 | Tier 6 (Select Care Drugs) | $0 | $0 | $0 |
|
Standard Retail Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $8 copay | $16 copay | $24 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) | $95 copay | $190 copay | $285 copay | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost | Tier 6 (Select Care Drugs) | $0 | $0 | $0 |
|
Preferred Mail Order Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $3 copay | $6 copay | $6 copay | Tier 2 (Non-Preferred Generic) | $8 copay | $16 copay | $16 copay | Tier 3 (Preferred Brand) | $35 copay | $70 copay | $70 copay | Tier 4 (Non-Preferred Brand) | $85 copay | $170 copay | $213 copay | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost | Tier 6 (Select Care Drugs) | $0 | $0 | $0 |
|
Standard Mail Order Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $8 copay | $16 copay | $24 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) | $95 copay | $190 copay | $285 copay | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost | Tier 6 (Select Care Drugs) | $0 | $0 | $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.
|
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 |
$0 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical 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: |
- $3 200 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. |
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 |
There is a limit to how much our plan will pay: $15 copay |
Ambulance Services |
$295 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): $15 copay |
Routine chiropractic visit (there is a limit to how much our plan will pay): $15 copay |
Dental Services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): $20 copay after you pay your deductible |
Diabetes Supplies and Services |
Diabetes monitoring supplies: You pay nothing |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: 15% of the cost |
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans): 15% of the cost |
Diagnostic tests and procedures: 0-15% of the cost depending on the service |
Lab services: You pay nothing |
Outpatient x-rays: $20 copay |
Therapeutic radiology services (such as radiation treatment for cancer): 15% of the cost |
Doctor’s Office Visits |
Primary care physician visit: You pay nothing |
Specialist visit: $20 copay |
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
15% 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: $20 copay |
Routine foot care: $20 copay |
Hearing Services |
Exam to diagnose and treat hearing and balance issues: $20 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. |
|
$250 copay per day for days 1 through 6 |
You pay nothing per day for days 7 through 90 |
|
Outpatient group therapy visit: $25 copay |
Outpatient individual therapy visit: $25 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): $25 copay |
Occupational therapy visit: $25 copay |
Physical therapy and speech and language therapy visit: $25 copay |
Outpatient Substance Abuse |
Group therapy visit: $25 copay |
Individual therapy visit: $25 copay |
Outpatient Surgery |
Ambulatory surgical center: $150 copay |
Outpatient hospital: $175 copay or 15% of the cost depending on the service |
Over-the-Counter Items |
Not Covered |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: 15% of the cost |
Related medical supplies: 15% of the cost |
Renal Dialysis |
20% of the cost |
Transportation |
Not covered |
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): $0-20 copay depending on the service |
Routine eye exam (for up to 1 every year): $10 copay |
Contact lenses (for up to 1 every two years): You pay nothing |
Eyeglasses (frames and lenses) (for up to 1 every two years): You pay nothing |
Eyeglasses frames (for up to 1 every two years): You pay nothing |
Eyeglasses lenses (for up to 1 every two years): You pay nothing |
Eyeglasses or contact lenses after cataract surgery: You pay nothing |
Our plan pays up to $250 every two years for eyewear. |
** 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. |
|
$250 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 |
|
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 |
$100 copay per day for days 21 through 100 |
|
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs1: 15% of the cost |
Other Part B drugs1: 15% of the cost |
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. |
Preferred Retail Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $3 copay | $6 copay | $9 copay | Tier 2 (Non-Preferred Generic) | $8 copay | $16 copay | $24 copay | Tier 3 (Preferred Brand) | $35 copay | $70 copay | $105 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 | Tier 6 (Select Care Drugs) | $0 | $0 | $0 |
|
Standard Retail Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $8 copay | $16 copay | $24 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) | $95 copay | $190 copay | $285 copay | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost | Tier 6 (Select Care Drugs) | $0 | $0 | $0 |
|
Preferred Mail Order Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $3 copay | $6 copay | $6 copay | Tier 2 (Non-Preferred Generic) | $8 copay | $16 copay | $16 copay | Tier 3 (Preferred Brand) | $35 copay | $70 copay | $70 copay | Tier 4 (Non-Preferred Brand) | $85 copay | $170 copay | $213 copay | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost | Tier 6 (Select Care Drugs) | $0 | $0 | $0 |
|
Standard Mail Order Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $8 copay | $16 copay | $24 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) | $95 copay | $190 copay | $285 copay | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost | Tier 6 (Select Care Drugs) | $0 | $0 | $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.
|
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: You pay nothing |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: 15% of the cost |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $20 copay |
Routine foot care: $20 copay |
Hearing Services |
Exam to diagnose and treat hearing and balance issues: $20 copay |
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit: $25 copay |
Individual therapy visit: $25 copay |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: 15% of the cost |
Related medical supplies: 15% 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: Preventive Dental Plus |
Benefits include:- Preventive Dental
- Comprehensive Dental
|
Additional $31.00 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. |
$35 per year. |
Our plan pays up to $1250 every year. |
** Important Information ** |
Package 1: Preventive Dental Plus |
Benefits include:- Preventive Dental
- Comprehensive Dental
|
Additional $31.00 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. |
$35 per year. |
Our plan pays up to $1250 every year. |