** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
Indiana University Health Plans - Medicare will reduce your Medicare Part B premium by up to $25. |
This plan does not have a deductible. |
** 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: 20% of the cost |
Other Part B drugs1: 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 |
Indiana University Health Plans - Medicare will reduce your Medicare Part B premium by up to $25. |
This plan does not have a deductible. |
** Outpatient Care and Services ** |
Acupuncture and Other Alternative Therapies |
Not covered |
Ambulance Services |
$225 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): $20 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 |
Dental services: $10 copay for a single office visit that includes: |
Dental x-ray(s) (for up to 1 every year) |
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans): $125 copay |
Diagnostic tests and procedures: $10 copay |
Lab services: $10 copay |
Outpatient x-rays: $25 copay |
Therapeutic radiology services (such as radiation treatment for cancer): $25 copay |
Doctor’s Office Visits |
Primary care physician visit: You pay nothing |
Specialist visit: $30 copay |
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
20% of the cost |
Emergency Care |
$65 copay |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $15 copay |
Hearing Services |
Routine hearing exam: You pay nothing |
Home Health Care |
You pay nothing |
Mental Health Care |
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. |
|
$250 copay per day for days 1 through 6 |
You pay nothing per day for days 7 through 90 |
|
Outpatient group therapy visit: $40 copay |
Outpatient individual therapy visit: $40 copay |
Outpatient Rehabilitation Services |
Occupational therapy visit: $15 copay |
Physical therapy and speech and language therapy visit: $15 copay |
Outpatient Substance Abuse |
Individual therapy visit: $25 copay |
Outpatient Surgery |
Ambulatory surgical center: $265 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 |
You pay nothing |
Transportation |
Not covered |
Urgently Needed Care |
$50 copay |
Vision Services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing |
Routine eye exam (for up to 1 every year): You pay nothing |
Contact lenses (for up to 1 every two years): You pay nothing |
Eyeglasses frames (for up to 1 every two years): $20 copay |
Eyeglasses lenses (for up to 1 every two years): $20 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. |
** Inpatient Care ** |
Inpatient Hospital Care |
Our plan covers 90 days for an inpatient hospital stay. |
$250 copay per day for days 1 through 7 |
You pay nothing per day for days 8 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. |
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: 20% of the cost |
Other Part B drugs1: 20% of the cost |
Our plan does not cover Part D prescription drug. |
** Outpatient Care ** |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $15 copay |
Hearing Services |
Routine hearing exam: You pay nothing |
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Individual therapy visit: $25 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. |