** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$45.00 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
$125 per year for some in-network and out-of-network services. |
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: |
- $2 500 for services you receive from in-network providers.
|
- $5 100 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 benefits from any provider. Contact us for services that apply. |
** Doctor and Hospital Choice ** |
Acupuncture |
There is a limit to how much our plan will pay: |
- Out-of-network: $0-15 copay depending on the service
|
** 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: 15% of the cost
|
- Out-of-network: 20% of the cost
|
Other Part B drugs1:- In-network: 15% 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 |
$45.00 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
$125 per year for some in-network and out-of-network services. |
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: |
- $2 500 for services you receive from in-network providers.
|
- $5 100 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 benefits from any provider. Contact us for services that apply. |
** Outpatient Care and Services ** |
Acupuncture |
There is a limit to how much our plan will pay: |
- Out-of-network: $0-15 copay depending on the service
|
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): |
- Out-of-network: $15 copay
|
Routine chiropractic visit (there is a limit to how much our plan will pay): |
- Out-of-network: $0-15 copay depending on the service
|
Dental services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): |
- Out-of-network: $40 copay
|
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: You pay nothing
|
Therapeutic shoes or inserts:- In-network: 15% of the cost
|
- 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: 15% of the cost
|
- Out-of-network: 20% of the cost
|
Diagnostic tests and procedures:- In-network: 0-15% of the cost depending on the service
|
- Out-of-network: 0-20% of the cost depending on the service
|
Lab services:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Outpatient x-rays: |
- Out-of-network: $20 copay
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: 15% 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: $40 copay
|
Durable medical equipment (wheelchairs, oxygen, etc.) |
- In-network: 15% of the cost
|
- Out-of-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: $40 copay
|
Hearing services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: $40 copay
|
Home health care |
- In-network: You pay nothing
|
- Out-of-network: $15 copay
|
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. |
The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. |
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: |
$175 copay per day for days 1 through 8 |
You pay nothing per day for days 9 through 90 |
|
|
Out-of-network: |
$200 copay per day for days 1 through 8 |
You pay nothing per day for days 9 through 190 |
|
Outpatient group therapy visit: |
- Out-of-network: $50 copay
|
Outpatient individual therapy visit: |
- Out-of-network: $50 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): |
- Out-of-network: $35 copay
|
Occupational therapy visit: |
- Out-of-network: $35 copay
|
Physical therapy and speech and language therapy visit: |
- Out-of-network: $35 copay
|
Outpatient substance abuse |
Group therapy visit: |
- Out-of-network: $50 copay
|
Individual therapy visit: |
- Out-of-network: $50 copay
|
Outpatient surgery |
Ambulatory surgical center: |
- Out-of-network: $175 copay
|
Outpatient hospital: |
- Out-of-network: $200 copay
|
Over-the-counter items |
Not Covered |
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 15% of the cost
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: 15% of the cost
|
- Out-of-network: 20% of the cost
|
Renal dialysis |
- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Transportation |
Not covered |
Urgently needed services |
$25-50 copay depending on the service |
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):- In-network: $0-25 copay depending on the service
|
- Out-of-network: $0-40 copay depending on the service
|
Routine eye exam (for up to 1 every year): |
- Out-of-network: $0-40 copay depending on the service
|
Contact lenses (for up to 1 every two years):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglasses (frames and lenses) (for up to 1 every two years):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglass frames (for up to 1 every two years):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglass lenses (for up to 1 every two years):- 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 $250 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: 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 |
The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
|
In-network: |
$175 copay per day for days 1 through 8 |
You pay nothing per day for days 9 through 90 |
You pay nothing per day for days 91 and beyond |
|
|
Out-of-network: |
$200 copay per day for days 1 through 8 |
You pay nothing per day for days 9 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: |
You pay nothing per day for days 1 through 20 |
$100 copay per day for days 21 through 100 |
|
|
Out-of-network: |
You pay nothing per day for days 1 through 20 |
$150 copay per day for days 21 through 100 |
|
Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs1:- In-network: 15% of the cost
|
- Out-of-network: 20% of the cost
|
Other Part B drugs1:- In-network: 15% 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: You pay nothing
|
Therapeutic shoes or inserts:- In-network: 15% of the cost
|
- 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: $40 copay
|
Hearing services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: $40 copay
|
** Outpatient Medical Services and Supplies ** |
Outpatient substance abuse |
Group therapy visit: |
- Out-of-network: $50 copay
|
Individual therapy visit: |
- Out-of-network: $50 copay
|
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 15% of the cost
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: 15% 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. |
** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
Package 1: Comprehensive Dental PPO |
Benefits include:- Preventive Dental
- Comprehensive Dental
|
Additional $39.00 per month. You must keep paying your Medicare Part B premium and your $45 monthly plan premium. |
$100 per year. |
Our plan pays up to $1 000 every year. Our plan has additional coverage limits for certain benefits. |
** Important Information ** |
Package 1: Comprehensive Dental PPO |
Benefits include:- Preventive Dental
- Comprehensive Dental
|
Additional $39.00 per month. You must keep paying your Medicare Part B premium and your $45 monthly plan premium. |
$100 per year. |
Our plan pays up to $1 000 every year. Our plan has additional coverage limits for certain benefits. |
** Cost ** |
Package 2: Preventive & Diagnostic Plus Dental PPO |
Benefits include: |
Additional $15.00 per month. You must keep paying your Medicare Part B premium and your $45 monthly plan premium. |
$35 per year. |
Our plan pays up to $500 every year. Our plan has additional coverage limits for certain benefits. |
** Important Information ** |
Package 2: Preventive & Diagnostic Plus Dental PPO |
Benefits include: |
Additional $15.00 per month. You must keep paying your Medicare Part B premium and your $45 monthly plan premium. |
$35 per year. |
Our plan pays up to $500 every year. Our plan has additional coverage limits for certain benefits. |