** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$18.00 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
$250 per year for out-of-network services. |
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: |
- $5 400 for services you receive from in-network providers.
|
- $5 400 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:- In-network: 20% of the cost
|
- 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 |
$18.00 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
$250 per year for out-of-network services. |
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: |
- $5 400 for services you receive from in-network providers.
|
- $5 400 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: $150 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: $45 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 1 every year):- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Oral exam (for up to 1 every year):- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Diabetes Supplies and Services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: 25% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 25% of the cost
|
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans):- In-network: $130-150 copay depending on the service
|
- Out-of-network: $150-170 copay depending on the service
|
Diagnostic tests and procedures:- In-network: $0-150 copay depending on the service
|
- Out-of-network: $110-170 copay depending on the service
|
Lab services: |
- Out-of-network: $25 copay
|
Outpatient x-rays:- In-network: $90-110 copay depending on the service
|
- Out-of-network: $110-170 copay depending on the service
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Doctor’s Office Visits |
Primary care physician visit: |
- Out-of-network: $25 copay
|
Specialist visit: |
- Out-of-network: $50 copay
|
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
- In-network: 20% of the cost
|
- Out-of-network: 25% 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: |
- 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
|
Our plan pays up to $100 every year for routine hearing exams from any provider. |
Home Health Care |
- In-network: You pay nothing
|
- Out-of-network: 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. |
|
In-network: |
$250 copay per day for days 1 through 5 |
You pay nothing per day for days 6 through 90 |
|
|
Out-of-network: |
30% of the cost per stay |
|
Outpatient group therapy visit: |
- Out-of-network: $50 copay
|
Outpatient individual therapy visit: |
- Out-of-network: $50 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: $45 copay
|
Occupational therapy visit: |
- Out-of-network: $45 copay
|
Physical therapy and speech and language therapy visit: |
- Out-of-network: $45 copay
|
Outpatient Substance Abuse |
Group therapy visit: |
- Out-of-network: $50 copay
|
Individual therapy visit: |
- Out-of-network: $50 copay
|
Outpatient Surgery |
Ambulatory surgical center:- In-network: 0-20% of the cost depending on the service
|
- Out-of-network: 25% of the cost
|
Outpatient hospital:- In-network: $0-30 copay or 0-20% of the cost depending on the service
|
- Out-of-network: $25-50 copay or 25% of the cost depending on the service
|
Over-the-Counter Items |
Not Covered |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 25% of the cost
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 25% of the cost
|
Renal Dialysis |
- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Transportation |
Not covered |
Urgently Needed Care |
$45 copay |
Vision Services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):- In-network: $0-30 copay depending on the service
|
- Out-of-network: $50 copay
|
Routine eye exam (for up to 1 every year):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Our plan pays up to $69 every year for routine eye exams from any provider. |
Contact lenses (for up to 1 every two years):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Our plan pays up to $80 every two years for contact lenses from any provider. |
Eyeglasses (frames and lenses) (for up to 1 every two years):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Our plan pays up to $100 every two years for eyeglasses (frames and lenses) from any provider. |
Eyeglasses or contact lenses after cataract surgery:- In-network: You pay nothing
|
- Out-of-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: $0-50 copay depending on the service
|
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 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. |
|
In-network: |
$255 copay per day for days 1 through 5 |
You pay nothing per day for days 6 through 90 |
|
|
Out-of-network: |
30% 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 20
|
- $130 copay per day for days 21 through 100
|
|
|
Out-of-network: |
25% of the cost per stay |
|
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs1:- In-network: 20% of the cost
|
- 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: You pay nothing
|
- Out-of-network: 25% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 25% 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
|
Our plan pays up to $100 every year for routine hearing exams from any provider. |
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit: |
- Out-of-network: $50 copay
|
Individual therapy visit: |
- Out-of-network: $50 copay
|
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 25% of the cost
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 25% of the cost
|
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |