** 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. |
$100 per year 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: |
- $6 600 for services you receive from in-network providers.
|
- $7 500 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 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 |
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: 40% of the cost
|
Other Part B drugs:- In-network: 20% of the cost
|
- Out-of-network: 40% of the cost
|
After you pay your yearly 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) | $0 | $0 | $0 | Tier 2 (Non-Preferred Generic) | $5 copay | $10 copay | $12.50 copay | Tier 3 (Preferred Brand) | $45 copay | $90 copay | $112.50 copay | Tier 4 (Non-Preferred Brand) | $85 copay | $170 copay | $212.50 copay | Tier 5 (Specialty Tier) | 30% of the cost | 30% of the cost | 30% of the cost |
|
Standard Mail Order Cost-SharingTier | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | Tier 2 (Non-Preferred Generic) | $10 copay | Tier 3 (Preferred Brand) | $90 copay | Tier 4 (Non-Preferred Brand) | $170 copay | Tier 5 (Specialty Tier) | 30% of the cost |
|
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. |
Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
|
Standard Retail Cost-SharingTier | Drugs Covered | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | $0 | $0 | $0 | Tier 2 (Non-Preferred Generic) | All | $5 copay | $10 copay | $12.50 copay |
|
Standard Mail Order Cost-SharingTier | Drugs Covered | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | $0 | Tier 2 (Non-Preferred Generic) | All | $10 copay |
|
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. |
$100 per year 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: |
- $6 600 for services you receive from in-network providers.
|
- $7 500 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 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 |
Not covered |
Ambulance Services |
|
- Out-of-network: $250 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: 40% of the cost
|
Dental Services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):- In-network: $40-65 copay depending on the service
|
- Out-of-network: 40% of the cost
|
Diabetes Supplies and Services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: 40% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 40% of the cost
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 40% of the cost
|
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans): |
- Out-of-network: 40% of the cost
|
Diagnostic tests and procedures:- In-network: You pay nothing
|
- Out-of-network: 40% of the cost
|
Lab services:- In-network: You pay nothing
|
- Out-of-network: 40% of the cost
|
Outpatient x-rays: |
- Out-of-network: 40% of the cost
|
Therapeutic radiology services (such as radiation treatment for cancer): |
- Out-of-network: 40% of the cost
|
Doctor’s Office Visits |
Primary care physician visit: |
- Out-of-network: 40% of the cost
|
Specialist visit: |
- Out-of-network: 40% of the cost
|
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
- In-network: 20% of the cost
|
- Out-of-network: 40% 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: 40% of the cost
|
Hearing Services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: 40% of the cost
|
Routine hearing exam: |
- Out-of-network: 40% of the cost
|
Hearing aid:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Our plan pays up to $500 every two years for hearing aids from an in-network provider and an additional $500 every two years from an out-of-network provider. |
Home Health Care |
- In-network: You pay nothing
|
- Out-of-network: 40% of the cost
|
Mental Health Care |
Inpatient visit: |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
|
In-network: |
- $250 copay per day for days 1 through 5
|
- $0 copay per day for days 6 through 90
|
You pay nothing per day for days 91 and beyond |
|
|
Out-of-network: |
40% of the cost per stay |
|
Outpatient group therapy visit: |
- Out-of-network: 40% of the cost
|
Outpatient individual therapy visit: |
- Out-of-network: 40% of the cost
|
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: 40% of the cost
|
Occupational therapy visit: |
- Out-of-network: 40% of the cost
|
Physical therapy and speech and language therapy visit: |
- Out-of-network: 40% of the cost
|
Outpatient Substance Abuse |
Group therapy visit: |
- Out-of-network: 40% of the cost
|
Individual therapy visit: |
- Out-of-network: 40% of the cost
|
Outpatient Surgery |
Ambulatory surgical center: |
- Out-of-network: 40% of the cost
|
Outpatient hospital: |
- Out-of-network: 40% of the cost
|
Over-the-Counter Items |
Not Covered |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 40% of the cost
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 40% of the cost
|
Renal Dialysis |
- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Transportation |
Not covered |
Urgently Needed Care |
$65 copay |
Vision Services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): |
- Out-of-network: 40% of the cost
|
Routine eye exam:- In-network: You pay nothing
|
- Out-of-network: 40% of the cost
|
Eyeglasses or contact lenses after cataract surgery:- In-network: You pay nothing
|
- Out-of-network: 40% of the cost
|
** 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: 40% of the cost
|
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: |
- $250 copay per day for days 1 through 5
|
- $0 copay per day for days 6 through 90
|
You pay nothing per day for days 91 and beyond |
|
|
Out-of-network: |
40% 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
|
- $150 copay per day for days 21 through 100
|
|
|
Out-of-network: |
40% 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: 40% of the cost
|
Other Part B drugs:- In-network: 20% of the cost
|
- Out-of-network: 40% of the cost
|
After you pay your yearly 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) | $0 | $0 | $0 | Tier 2 (Non-Preferred Generic) | $5 copay | $10 copay | $12.50 copay | Tier 3 (Preferred Brand) | $45 copay | $90 copay | $112.50 copay | Tier 4 (Non-Preferred Brand) | $85 copay | $170 copay | $212.50 copay | Tier 5 (Specialty Tier) | 30% of the cost | 30% of the cost | 30% of the cost |
|
Standard Mail Order Cost-SharingTier | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | Tier 2 (Non-Preferred Generic) | $10 copay | Tier 3 (Preferred Brand) | $90 copay | Tier 4 (Non-Preferred Brand) | $170 copay | Tier 5 (Specialty Tier) | 30% of the cost |
|
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. |
Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
|
Standard Retail Cost-SharingTier | Drugs Covered | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | $0 | $0 | $0 | Tier 2 (Non-Preferred Generic) | All | $5 copay | $10 copay | $12.50 copay |
|
Standard Mail Order Cost-SharingTier | Drugs Covered | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | $0 | Tier 2 (Non-Preferred Generic) | All | $10 copay |
|
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: 40% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 40% of the cost
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 40% 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: 40% of the cost
|
Hearing Services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: 40% of the cost
|
Routine hearing exam: |
- Out-of-network: 40% of the cost
|
Hearing aid:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Our plan pays up to $500 every two years for hearing aids from an in-network provider and an additional $500 every two years from an out-of-network provider. |
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit: |
- Out-of-network: 40% of the cost
|
Individual therapy visit: |
- Out-of-network: 40% of the cost
|
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 40% of the cost
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 40% of the cost
|
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |