** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
You pay nothing |
You pay nothing |
No. This plan does not have any limits. |
In this plan you will pay nothing for services from any provider. |
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 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: You pay nothing |
Other Part B drugs: You pay nothing |
You may get your drugs at network retail pharmacies and mail order pharmacies. |
You pay the following: |
Standard Retail Cost-SharingTier | Your cost |
---|
Tier 1 (Generic Drugs) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 2 (Brand Drugs) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Non-Medicare Rx/OTC Drugs) | $0 |
|
Standard Mail Order Cost-SharingTier | Your cost |
---|
Tier 1 (Generic Drugs) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 2 (Brand Drugs) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Non-Medicare Rx/OTC Drugs) | $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.
|
You pay nothing |
** Important Information ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
You pay nothing |
You pay nothing |
No. This plan does not have any limits. |
In this plan you will pay nothing for services from any provider. |
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 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 |
Additional Home Care Services |
Home and community based services: You pay nothing |
Private duty nursing services (for up to 16 hours every day): You pay nothing |
Additional Services |
Mental Health and Addiction Services from a Certified Provider: You pay nothing |
Medically Necessary Wheelchair Van: You pay nothing |
Ambulance Services |
You pay nothing |
Chiropractic Care |
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing |
Dental Services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing |
Preventive dental services: |
Cleaning (for up to 1 every year): You pay nothing |
Dental x-ray(s) (for up to 1 every year): You pay nothing |
Fluoride treatment (for up to 1 every year): You pay nothing |
Oral exam (for up to 1 every year): You pay nothing |
Diabetes Supplies and Services |
Diabetes monitoring supplies: You pay nothing |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: You pay nothing |
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans): You pay nothing |
Diagnostic tests and procedures: You pay nothing |
Lab services: You pay nothing |
Outpatient x-rays: You pay nothing |
Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing |
Doctor’s Office Visits |
Primary care physician visit: You pay nothing |
Specialist visit: You pay nothing |
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
You pay nothing |
Incontinence Garments: You pay nothing |
Emergency Care |
You pay nothing |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing |
Hearing Services |
Exam to diagnose and treat hearing and balance issues: You pay nothing |
Routine hearing exam: You pay nothing |
Hearing aid fitting/evaluation: You pay nothing |
Hearing aid: You pay nothing |
Home Health Care |
You pay nothing |
Additional hours of care: You pay nothing |
Mental Health Care |
Inpatient visit: |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
You pay nothing |
Outpatient group therapy visit: You pay nothing |
Outpatient individual therapy visit: You pay nothing |
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): You pay nothing |
Occupational therapy visit: You pay nothing |
Physical therapy and speech and language therapy visit: You pay nothing |
Outpatient Substance Abuse |
Group therapy visit: You pay nothing |
Individual therapy visit: You pay nothing |
Outpatient Surgery |
Ambulatory surgical center: You pay nothing |
Outpatient hospital: You pay nothing |
Freestanding birth center services: You pay nothing |
Over-the-Counter Items |
Not Covered |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: You pay nothing |
Related medical supplies: You pay nothing |
Renal Dialysis |
You pay nothing |
Transportation |
Not covered |
Urgently Needed Care |
You pay nothing |
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 two years): You pay nothing |
Eyeglasses (frames and lenses) (for up to 1 every two years): You pay nothing |
Eyeglass frames (for up to 1 every two years): You pay nothing |
Eyeglass lenses (for up to 1 every two years): You pay nothing |
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. |
** 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. |
Early and periodic screening diagnostic and treatment (EPSDT) services: You pay nothing |
Family planning services: You pay nothing |
Tobacco cessation counseling for pregnant women: You pay nothing |
** Inpatient Care ** |
Inpatient Hospital Care |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
You pay nothing |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |
Skilled Nursing Facility (SNF) |
Our plan covers an unlimited number of days in a SNF. |
You pay nothing |
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs: You pay nothing |
Other Part B drugs: You pay nothing |
You may get your drugs at network retail pharmacies and mail order pharmacies. |
You pay the following: |
Standard Retail Cost-SharingTier | Your cost |
---|
Tier 1 (Generic Drugs) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 2 (Brand Drugs) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Non-Medicare Rx/OTC Drugs) | $0 |
|
Standard Mail Order Cost-SharingTier | Your cost |
---|
Tier 1 (Generic Drugs) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 2 (Brand Drugs) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Non-Medicare Rx/OTC Drugs) | $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.
|
You pay nothing |
Additional Home Care Services |
Home and community based services: You pay nothing |
Private duty nursing services (for up to 16 hours every day): You pay nothing |
** Outpatient Care ** |
Diabetes Supplies and Services |
Diabetes monitoring supplies: You pay nothing |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: You pay nothing |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing |
Hearing Services |
Exam to diagnose and treat hearing and balance issues: You pay nothing |
Routine hearing exam: You pay nothing |
Hearing aid fitting/evaluation: You pay nothing |
Hearing aid: You pay nothing |
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit: You pay nothing |
Individual therapy visit: You pay nothing |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: You pay nothing |
Related medical supplies: You pay nothing |
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |