** 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. |
$0 to $74 per year for Part D prescription drugs except for drugs listed on Tier 1 which are excluded from the deductible. |
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. |
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility. |
Your yearly limit(s) in this plan: |
- $6 700 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. Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document. 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 |
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: 0% or 20% of the cost |
Other Part B drugs1: 0% or 20% of the cost |
You pay the following:
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Standard Retail Cost-Sharing Tier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | $0 | Tier 2 (Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Not Offered | |
Standard Mail Order Cost-Sharing Tier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | $0 | Tier 2 (Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Not Offered | |
Preferred Mail Order Cost-Sharing Tier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | $0 | Tier 2 (Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Not Offered | |
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 but may pay more than you pay at an in-network pharmacy.
|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay nothing for all 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. |
$0 to $74 per year for Part D prescription drugs except for drugs listed on Tier 1 which are excluded from the deductible. |
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. |
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility. |
Your yearly limit(s) in this plan: |
- $6 700 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. Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document. 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 |
Not covered |
Ambulance |
$0 or $200 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): $0 or $10 copay |
Routine chiropractic visit (for up to 12 every year): $10 copay |
Dental services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): $0 or $10 copay |
Preventive dental services: |
Cleaning (for up to 1 every six months): You pay nothing |
Dental x-ray(s) (for up to 1): You pay nothing |
Oral exam (for up to 1 every six months): 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 (Costs for these services may be different if received in an outpatient surgery setting) |
Diagnostic radiology services (such as MRIs CT scans): 0% or 20% of the cost |
Diagnostic tests and procedures: $0-50 copay depending on the service |
Lab services: You pay nothing |
Outpatient x-rays: You pay nothing |
Therapeutic radiology services (such as radiation treatment for cancer): $0 or $10 copay or 0% or 20% of the cost depending on the service |
Doctor's office visits |
Primary care physician visit: You pay nothing |
Specialist visit: $0 or $10 copay |
Durable medical equipment (wheelchairs, oxygen, etc.) |
0% or 20% of the cost |
If you go to a preferred vendor your cost may be less. Contact us for a list of preferred vendors. |
Emergency care |
$0 or $75 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: $0 or $10 copay |
Hearing services |
Exam to diagnose and treat hearing and balance issues: $0 or $10 copay |
Routine hearing exam (for up to 1 every year): You pay nothing |
Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing |
Hearing aid: You pay nothing |
Our plan pays up to $350 every year for hearing aids. |
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. |
|
$0 or $195 copay per day for days 1 through 7 |
You pay nothing per day for days 8 through 90 |
|
Outpatient group therapy visit: $0 or $20 copay |
Outpatient individual therapy visit: $0 or $20 copay |
Outpatient rehabilitation |
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $0 or $10 copay |
Occupational therapy visit: $0 or $10 copay |
Physical therapy and speech and language therapy visit: $0 or $10 copay |
Outpatient substance abuse |
Group therapy visit: $0 or $40 copay |
Individual therapy visit: $0 or $40 copay |
Outpatient surgery |
Ambulatory surgical center: $0 or $75 copay |
Outpatient hospital: $0 or $75-150 copay depending on the service |
Over-the-counter items |
Not Covered |
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices: 0% or 20% of the cost |
Related medical supplies: 0% or 20% of the cost |
Renal dialysis |
0% or 20% of the cost |
Transportation |
You pay nothing |
Urgently needed services |
$0 or $25 copay |
If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services. 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): $0-10 copay depending on the service |
Routine eye exam (for up to 1 every year): You pay nothing |
Contact lenses (for up to 1 every year): You pay nothing |
Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing |
Eyeglass frames (for up to 1 every year): You pay nothing |
Eyeglass lenses (for up to 1 every year): You pay nothing |
Eyeglasses or contact lenses after cataract surgery: You pay nothing |
Our plan pays up to $100 every year 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
- Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
- Depression screening
- Diabetes screenings
- 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. |
Annual physical exam: You pay nothing |
** Inpatient Care ** |
Inpatient hospital care |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
|
$0 or $195 copay per day for days 1 through 5 |
You pay nothing per day for days 6 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 |
$0 or $160 copay per day for days 21 through 100 |
|
Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs1: 0% or 20% of the cost |
Other Part B drugs1: 0% or 20% of the cost |
You pay the following:
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Standard Retail Cost-Sharing Tier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | $0 | Tier 2 (Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Not Offered | |
Standard Mail Order Cost-Sharing Tier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | $0 | Tier 2 (Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Not Offered | |
Preferred Mail Order Cost-Sharing Tier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | $0 | Tier 2 (Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Not Offered | |
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 but may pay more than you pay at an in-network pharmacy.
|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay nothing for all drugs. |
** 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: $0 or $10 copay |
Hearing services |
Exam to diagnose and treat hearing and balance issues: $0 or $10 copay |
Routine hearing exam (for up to 1 every year): You pay nothing |
Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing |
Hearing aid: You pay nothing |
Our plan pays up to $350 every year for hearing aids. |
** Outpatient Medical Services and Supplies ** |
Outpatient substance abuse |
Group therapy visit: $0 or $40 copay |
Individual therapy visit: $0 or $40 copay |
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices: 0% or 20% of the cost |
Related medical supplies: 0% or 20% of the cost |
** Additional Benefits ** |
Inpatient mental health care |
For inpatient mental health care see the "Mental Health Care" section. |