** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$24.00 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.
|
- $5 000 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. |
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:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Other Part B drugs1:- 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 |
$24.00 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.
|
- $5 000 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. |
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 |
|
- Out-of-network: $150 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: 20% of the cost
|
Dental services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): |
- Out-of-network: 20% of the cost
|
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: $125-175 copay depending on the service
|
- Out-of-network: 20% of the cost
|
Diagnostic tests and procedures: |
- Out-of-network: 20% of the cost
|
Lab services:- In-network: $0-15 copay depending on the service
|
- Out-of-network: 20% of the cost
|
Outpatient x-rays: |
- Out-of-network: 20% of the cost
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Doctor's office visits |
Primary care physician visit: |
- Out-of-network: $20 copay
|
Specialist visit: |
- Out-of-network: $45 copay
|
Durable medical equipment (wheelchairs, oxygen, etc.) |
- In-network: 20% of the cost
|
- Out-of-network: 0-40% of the cost depending on the equipment
|
Emergency care |
$75 copay |
If you are immediately admitted to the hospital 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 (for up to 1 every year): |
- Out-of-network: 20% of the cost
|
Home health care |
- In-network: 10% of the cost
|
- 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: |
$225 copay per day for days 1 through 7 |
You pay nothing per day for days 8 through 90 |
|
|
Out-of-network: |
$350 copay per day for days 1 through 7 |
You pay nothing per day for days 8 through 90 |
|
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: $350 copay
|
Outpatient hospital:- In-network: $0-225 copay depending on the service
|
- Out-of-network: $350 copay
|
Over-the-counter items |
Not Covered |
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 0-20% of the cost depending on the device
|
- Out-of-network: 0-40% of the cost depending on the device
|
Related medical supplies:- In-network: 0-20% of the cost depending on the supply
|
- Out-of-network: 0-40% of the cost depending on the supply
|
Renal dialysis |
- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
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: $0-35 copay depending on the service
|
- Out-of-network: 20% of the cost
|
Routine eye exam (for up to 1 every two years): |
- Out-of-network: 20% of the cost
|
Contact lenses:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglasses (frames and lenses):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglass frames:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglass lenses:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglasses or contact lenses after cataract surgery:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Our plan pays up to $100 every two years for eyewear from any provider. |
** 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: 20% 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
- 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: |
$225 copay per day for days 1 through 7 |
You pay nothing per day for days 8 through 90 |
You pay nothing per day for days 91 and beyond |
|
|
Out-of-network: |
$350 copay per day for days 1 through 7 |
You pay nothing per day for days 8 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. |
|
In-network: |
$40 copay per day for days 1 through 20 |
$125 copay per day for days 21 through 100 |
|
|
Out-of-network: |
20% of the cost per stay |
20% of the cost per day for days 1 through 100 |
|
Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs1:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Other Part B drugs1:- 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 (for up to 1 every year): |
- Out-of-network: 20% of the cost
|
** 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: 0-20% of the cost depending on the device
|
- Out-of-network: 0-40% of the cost depending on the device
|
Related medical supplies:- In-network: 0-20% of the cost depending on the supply
|
- Out-of-network: 0-40% of the cost depending on the supply
|
** Additional Benefits ** |
Inpatient mental health care |
For inpatient mental health care see the "Mental Health Care" section. |
** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
Package 1: Preventive Dental |
Benefits include: |
Additional $24.00 per month. You must keep paying your Medicare Part B premium and your $24 monthly plan premium. |
This package does not have a deductible. |
No. There is no limit to how much our plan will pay for benefits in this package. |
** Important Information ** |
Package 1: Preventive Dental |
Benefits include: |
Additional $24.00 per month. You must keep paying your Medicare Part B premium and your $24 monthly plan premium. |
This package does not have a deductible. |
No. There is no limit to how much our plan will pay for benefits in this package. |