** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
Some services may require a monthly payment amount. |
You pay nothing |
In this plan you will pay nothing for services from any provider. |
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 |
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-Sharing Tier | Your cost |
---|
Tier 1 (Generic Drugs) | 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 2 (Brand Drugs) | 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 (Non-Medicare Rx/OTC Drugs) | $0 | |
Standard Mail Order Cost-Sharing Tier | Your cost |
---|
Tier 1 (Generic Drugs) | 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 2 (Brand Drugs) | 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 (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 |
Some services may require a monthly payment amount. |
You pay nothing |
In this plan you will pay nothing for services from any provider. |
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 |
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 |
Adult Day Health Services: You pay nothing |
Alternative Meals Services: You pay nothing |
Assisted Living Services: You pay nothing |
Choices Home Care Assistant: You pay nothing |
Chore Services: You pay nothing |
Community Transition: You pay nothing |
Emergency Response Services: You pay nothing |
Enhanced Community Living Services: You pay nothing |
Home Care Attendant: You pay nothing |
Home Delivered Meals: You pay nothing |
Home Medical Equipment and Supplemental Adaptive and Assistive Service: You pay nothing (there is a limit to how much our plan will pay) |
Home Modification Maintenance and Repair: You pay nothing (there is a limit to how much our plan will pay) |
Homemaker Services: You pay nothing |
Independent Living Assistance: You pay nothing |
Nutritional Consultation: You pay nothing |
Out of Home Respite Services: You pay nothing |
Personal Care Services: You pay nothing |
Pest Control: You pay nothing |
Social Work Counseling: You pay nothing |
Waiver Nursing Services: You pay nothing |
Waiver Transportation: You pay nothing |
Ambulance |
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 (Costs for these services may be different if received in an outpatient surgery setting) |
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 |
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 services |
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
- 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. |
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-Sharing Tier | Your cost |
---|
Tier 1 (Generic Drugs) | 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 2 (Brand Drugs) | 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 (Non-Medicare Rx/OTC Drugs) | $0 | |
Standard Mail Order Cost-Sharing Tier | Your cost |
---|
Tier 1 (Generic Drugs) | 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 2 (Brand Drugs) | 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 (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. |