** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$0 per month. |
Triple S Advantage will reduce your Medicare Part B premium by up to $10. |
This plan does not have a deductible. |
This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs). |
This plan does not have a deductible for Part D prescription drugs. |
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. |
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility. |
Your yearly limit(s) in this plan: |
- $2 500 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. Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document. 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 |
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: You pay nothing |
Other Part B drugs1: You pay nothing |
In 2016 you will pay the following amounts for prescription drugs: Deductible Level 0 (Low Income Threshold 0 - 50%) and Level 1 (Low Income Threshold 51% - 100%) $1 for generic drugs $3 for brand drugs
|
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
|
** Important Information ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$0 per month. |
Triple S Advantage will reduce your Medicare Part B premium by up to $10. |
This plan does not have a deductible. |
This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs). |
This plan does not have a deductible for Part D prescription drugs. |
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. |
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility. |
Your yearly limit(s) in this plan: |
- $2 500 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. Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document. 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 |
Not covered |
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 |
Routine chiropractic visit (for up to 5 every year): 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 |
Dental services: $1 copay for a single office visit that includes: |
Cleaning (for up to 1 every six months) |
Dental x-ray(s) (for up to 1) |
Fluoride treatment (for up to 1 every six months) |
Oral exam (for up to 1 every six months) |
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 |
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 |
Routine foot care (for up to 4 visit(s) every year): You pay nothing |
Hearing services |
Exam to diagnose and treat hearing and balance issues: You pay nothing |
Routine hearing exam (for up to 1 every year): You pay nothing |
Home health care |
You pay nothing |
Mental health care |
Inpatient visit: |
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. |
You pay nothing |
You pay nothing per day for days 91 and beyond |
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 |
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 year): 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. |
Annual physical exam: You pay nothing |
** 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. |
You pay nothing |
You pay nothing per day for days 91 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. |
You pay nothing |
Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs1: You pay nothing |
Other Part B drugs1: You pay nothing |
In 2016 you will pay the following amounts for prescription drugs: Deductible Level 0 (Low Income Threshold 0 - 50%) and Level 1 (Low Income Threshold 51% - 100%) $1 for generic drugs $3 for brand drugs
|
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
|
** 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 |
Routine foot care (for up to 4 visit(s) every year): You pay nothing |
Hearing services |
Exam to diagnose and treat hearing and balance issues: You pay nothing |
Routine hearing exam (for up to 1 every year): 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. |