** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$58.4 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.
|
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 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 |
- In-network: $15 copay. You are covered for up to 6 visit(s) every year.
|
** 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: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the drug
|
Other Part B drugs1:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the drug
|
You pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
|
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) | $3 copay | $9 copay | Tier 2 (Generic) | $5 copay | $15 copay | Tier 3 (Preferred Brand) | $15 copay | $45 copay | Tier 4 (Non-Preferred Brand) | $30 copay | $90 copay | Tier 5 (Specialty Tier) | 25% of the cost | Not Offered | |
Standard Mail Order Cost-Sharing Tier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $3 copay | $6 copay | Tier 2 (Generic) | $5 copay | $10 copay | Tier 3 (Preferred Brand) | $15 copay | $30 copay | Tier 4 (Non-Preferred Brand) | $30 copay | $60 copay | Tier 5 (Specialty Tier) | 25% of the cost | 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.
|
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap. |
Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
|
Standard Retail Cost-Sharing Tier | Drugs Covered | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | $3 copay | $9 copay | Tier 2 (Generic) | All | $5 copay | $15 copay | |
Standard Mail Order Cost-Sharing Tier | Drugs Covered | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | $3 copay | $6 copay | Tier 2 (Generic) | All | $5 copay | $10 copay | |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of: - $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
|
** Important Information ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$58.4 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.
|
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 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 |
- In-network: $15 copay. You are covered for up to 6 visit(s) every year.
|
Ambulance |
- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
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: 0-20% of the cost depending on the service
|
Routine chiropractic visit:- In-network: $3 copay. You are covered for up to 6 every year.
|
- Out-of-network: 0-20% of the cost depending on the service. There may be a limit to how often these services are covered.
|
Dental services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):- In-network: 5% of the cost
|
- Out-of-network: 0-20% of the cost depending on the service
|
Preventive dental services: |
Cleaning:- In-network: You pay nothing. You are covered for up to 1 every six months.
|
- Out-of-network: 0-20% of the cost depending on the service. 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 three years.
|
- Out-of-network: 0-20% of the cost depending on the service. There may be a limit to how often these services are covered.
|
Fluoride treatment:- In-network: You pay nothing. You are covered for up to 1 every six months.
|
- Out-of-network: 0-20% of the cost depending on the service. 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 three years.
|
- Out-of-network: 0-20% of the cost depending on the service. There may be a limit to how often these services are covered.
|
Our plan pays up to $1 000 every year for preventive dental services from an in-network provider. |
Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the supply
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the supply
|
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: 0-5% of the cost depending on the service
|
- Out-of-network: 0-20% of the cost depending on the service
|
Diagnostic tests and procedures:- In-network: 0-5% of the cost depending on the service
|
- Out-of-network: 0-20% of the cost depending on the service
|
Lab services:- In-network: 0-20% of the cost depending on the service
|
- Out-of-network: 0-20% of the cost depending on the service
|
Outpatient x-rays:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: 0-5% of the cost depending on the service
|
- Out-of-network: 0-20% of the cost depending on the service
|
Doctor's office visits |
Primary care physician visit:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Specialist visit: |
- Out-of-network: 0-20% of the cost depending on the service
|
Durable medical equipment (wheelchairs, oxygen, etc.) |
- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the equipment
|
Emergency care |
$45 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: 0-20% of the cost depending on the service
|
Hearing services |
Exam to diagnose and treat hearing and balance issues:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Routine hearing exam:- In-network: You pay nothing. You are covered for up to 1 every year.
|
- Out-of-network: 0-20% of the cost depending on the service. There may be a limit to how often these services are covered.
|
Hearing aid fitting/evaluation:- In-network: You pay nothing. You are covered for up to 1 every year.
|
- Out-of-network: 0-20% of the cost depending on the service. There may be a limit to how often these services are covered.
|
Hearing aid:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost for each hearing aid depending on the type
|
Our plan pays up to $400 every year for hearing aids from an in-network provider. |
Home health care |
- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
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: You pay nothing
|
|
Out-of-network: |
20% of the cost per stay |
|
Outpatient group therapy visit: |
- Out-of-network: 0-20% of the cost depending on the service
|
Outpatient individual therapy visit: |
- Out-of-network: 0-20% of the cost depending on the service
|
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):- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Occupational therapy visit:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Physical therapy and speech and language therapy visit:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Outpatient substance abuse |
Group therapy visit: |
- Out-of-network: 0-20% of the cost depending on the service
|
Individual therapy visit: |
- Out-of-network: 0-20% of the cost depending on the service
|
Outpatient surgery |
Ambulatory surgical center:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Outpatient hospital:- In-network: $0-45 copay or 0-20% of the cost depending on the service
|
- Out-of-network: 0-20% of the cost depending on the service
|
Over-the-counter items |
Please visit our website to see our list of covered over-the-counter items. |
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 0-20% of the cost depending on the device
|
- Out-of-network: 0-20% of the cost depending on the device
|
Related medical supplies:- In-network: 10% of the cost
|
- Out-of-network: 0-20% of the cost depending on the supply
|
Renal dialysis |
- In-network: 10% of the cost
|
- Out-of-network: 0-20% of the cost depending on the service
|
Transportation |
Not covered |
Urgently needed services |
$10 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):- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Routine eye exam:- In-network: You pay nothing. You are covered for up to 1 every year.
|
- Out-of-network: 0-20% of the cost depending on the service. There may be a limit to how often these services are covered.
|
Contact lenses:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Eyeglasses (frames and lenses):- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Eyeglass frames:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Eyeglass lenses:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Eyeglasses or contact lenses after cataract surgery:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Our plan pays up to $250 every two years for eyewear from an in-network 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: 0-20% of the cost depending on the service
|
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 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: You pay nothing
|
|
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: You pay nothing
|
|
Out-of-network: |
20% of the cost per stay |
|
Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs1:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the drug
|
Other Part B drugs1:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the drug
|
You pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
|
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) | $3 copay | $9 copay | Tier 2 (Generic) | $5 copay | $15 copay | Tier 3 (Preferred Brand) | $15 copay | $45 copay | Tier 4 (Non-Preferred Brand) | $30 copay | $90 copay | Tier 5 (Specialty Tier) | 25% of the cost | Not Offered | |
Standard Mail Order Cost-Sharing Tier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $3 copay | $6 copay | Tier 2 (Generic) | $5 copay | $10 copay | Tier 3 (Preferred Brand) | $15 copay | $30 copay | Tier 4 (Non-Preferred Brand) | $30 copay | $60 copay | Tier 5 (Specialty Tier) | 25% of the cost | 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.
|
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap. |
Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
|
Standard Retail Cost-Sharing Tier | Drugs Covered | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | $3 copay | $9 copay | Tier 2 (Generic) | All | $5 copay | $15 copay | |
Standard Mail Order Cost-Sharing Tier | Drugs Covered | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | All | $3 copay | $6 copay | Tier 2 (Generic) | All | $5 copay | $10 copay | |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of: - $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
|
** Outpatient Care ** |
Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the supply
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the supply
|
Foot care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: |
- Out-of-network: 0-20% of the cost depending on the service
|
Hearing services |
Exam to diagnose and treat hearing and balance issues:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Routine hearing exam:- In-network: You pay nothing. You are covered for up to 1 every year.
|
- Out-of-network: 0-20% of the cost depending on the service. There may be a limit to how often these services are covered.
|
Hearing aid fitting/evaluation:- In-network: You pay nothing. You are covered for up to 1 every year.
|
- Out-of-network: 0-20% of the cost depending on the service. There may be a limit to how often these services are covered.
|
Hearing aid:- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost for each hearing aid depending on the type
|
Our plan pays up to $400 every year for hearing aids from an in-network provider. |
** Outpatient Medical Services and Supplies ** |
Outpatient substance abuse |
Group therapy visit: |
- Out-of-network: 0-20% of the cost depending on the service
|
Individual therapy visit: |
- Out-of-network: 0-20% of the cost depending on the service
|
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 0-20% of the cost depending on the device
|
- Out-of-network: 0-20% of the cost depending on the device
|
Related medical supplies:- In-network: 10% of the cost
|
- Out-of-network: 0-20% of the cost depending on the supply
|
** Additional Benefits ** |
Inpatient mental health care |
For inpatient mental health care see the "Mental Health Care" section. |