** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$39.00 per month. In addition you must keep paying your Medicare Part B premium. |
This plan does not have a 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. |
Your yearly limit(s) in this plan: |
- $3 400 for services you receive from in-network providers.
|
- $10 000 for services you receive from out-of-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. Please note that you will still need to pay your monthly premiums. |
** 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 drugs:- In-network: $25-75 copay depending on the drug
|
- Out-of-network: 20% of the cost
|
Other Part B drugs:- 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 |
$39.00 per month. In addition you must keep paying your Medicare Part B premium. |
This plan does not have a 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. |
Your yearly limit(s) in this plan: |
- $3 400 for services you receive from in-network providers.
|
- $10 000 for services you receive from out-of-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. Please note that you will still need to pay your monthly premiums. |
** Outpatient Care and Services ** |
Acupuncture |
Not covered |
Ambulance |
|
- Out-of-network: $100 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):- In-network: You pay nothing
|
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: 20% of the cost
|
Preventive dental services: |
Cleaning:- In-network: You pay nothing. You are covered for up to 1 every year.
|
- Out-of-network: You pay nothing. There may be a limit to how often these services are covered.
|
Dental x-ray(s):- In-network: You pay nothing. You are covered for up to 1 every year.
|
- Out-of-network: You pay nothing. There may be a limit to how often these services are covered.
|
Oral exam:- In-network: You pay nothing. You are covered for up to 1 every year.
|
- Out-of-network: You pay nothing. There may be a limit to how often these services are covered.
|
Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
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):- In-network: 10% of the cost
|
- Out-of-network: 20% of the cost
|
Diagnostic tests and procedures:- In-network: 10% of the cost
|
- Out-of-network: 20% of the cost
|
Lab services:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Outpatient x-rays:- In-network: 10% of the cost
|
- Out-of-network: 20% of the cost
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: 10% of the cost
|
- Out-of-network: 20% of the cost
|
Doctor's office visits |
Primary care physician visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Specialist visit: |
- Out-of-network: 20% of the cost
|
Durable medical equipment (wheelchairs, oxygen, etc.) |
- In-network: 20% of the cost
|
Emergency care |
$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: |
- Out-of-network: 20% of the cost
|
Hearing services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: 20% of the cost
|
Routine hearing exam:- In-network: You pay nothing. You are covered for up to 1 every year.
|
Home health care |
- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
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: |
$400 copay per stay |
|
|
Out-of-network: |
20% of the cost per stay |
|
Outpatient group therapy visit: |
- Out-of-network: 20% of the cost
|
Outpatient individual therapy visit: |
- Out-of-network: 20% of the cost
|
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): |
- Out-of-network: 20% of the cost
|
Occupational therapy visit: |
- Out-of-network: 20% of the cost
|
Physical therapy and speech and language therapy visit: |
- Out-of-network: 20% of the cost
|
Outpatient substance abuse |
Group therapy visit: |
- Out-of-network: 20% of the cost
|
Individual therapy visit: |
- Out-of-network: 20% of the cost
|
Outpatient surgery |
Ambulatory surgical center: |
- Out-of-network: 20% of the cost
|
Outpatient hospital:- In-network: $200 copay or 10% of the cost depending on the service
|
- Out-of-network: 20% 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: 20% of the cost
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Renal dialysis |
- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Transportation |
Not covered |
Urgently needed services |
$35 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: 20% of the cost
|
Routine eye exam:- In-network: You pay nothing. You are covered for up to 1 every year.
|
Eyeglasses or contact lenses after cataract surgery:- In-network: You pay nothing
|
- Out-of-network: 20% 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: 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. |
** Inpatient Care ** |
Inpatient hospital care |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
|
In-network: |
$400 copay per stay |
You pay nothing per day for days 91 and beyond |
|
|
Out-of-network: |
20% 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: |
$40 copay per day for days 1 through 20 |
You pay nothing per day for days 21 through 100 |
|
|
Out-of-network: |
20% of the cost per stay |
|
Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs:- In-network: $25-75 copay depending on the drug
|
- Out-of-network: 20% of the cost
|
Other Part B drugs:- 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: 20% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 20% 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: 20% of the cost
|
Hearing services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: 20% of the cost
|
Routine hearing exam:- In-network: You pay nothing. You are covered for up to 1 every year.
|
** Outpatient Medical Services and Supplies ** |
Outpatient substance abuse |
Group therapy visit: |
- Out-of-network: 20% of the cost
|
Individual therapy visit: |
- Out-of-network: 20% of the cost
|
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
** Additional Benefits ** |
Inpatient mental health care |
For inpatient mental health care see the "Mental Health Care" section. |