** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$25.00 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
$500 per year for 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: |
- $6 700 for services you receive from any provider.
|
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 |
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:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Other Part B drugs:- 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 |
$25.00 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
$500 per year for 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: |
- $6 700 for services you receive from any provider.
|
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 |
Not covered |
Ambulance |
|
- Out-of-network: $300 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 copay
|
Dental services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): |
- Out-of-network: $45 copay or 20% of the cost depending on the service
|
Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: 0-20% of the cost depending on the supply
|
- 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: 20% 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: $45-295 copay depending on the service
|
- Out-of-network: $45-295 copay depending on the service
|
Diagnostic tests and procedures:- In-network: $0-105 copay depending on the service
|
- Out-of-network: $0-105 copay depending on the service
|
Lab services:- In-network: $0-95 copay depending on the service
|
- Out-of-network: $0-105 copay depending on the service
|
Outpatient x-rays:- In-network: $15-105 copay depending on the service
|
- Out-of-network: $15-105 copay depending on the service
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: $45 copay or 20% of the cost depending on the service
|
- Out-of-network: $45 copay or 20% of the cost depending on the service
|
Doctor's office visits |
Primary care physician visit: |
- Out-of-network: $15-40 copay depending on the service
|
Specialist visit: |
- Out-of-network: $45 copay or 20% of the cost depending on the service
|
Durable medical equipment (wheelchairs, oxygen, etc.) |
- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
If you go to a preferred vendor your cost may be less. Contact us for a list of preferred vendors. |
Emergency care |
$75 copay |
Foot care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: |
- Out-of-network: $45 copay or 20% of the cost depending on the service
|
Hearing services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: $45 copay or 20% of the cost depending on the service
|
Home health care |
- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
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: |
$295 copay per day for days 1 through 5 |
You pay nothing per day for days 6 through 90 |
|
|
Out-of-network: |
$295 copay per day for days 1 through 5 |
You pay nothing per day for days 6 through 90 |
|
Outpatient group therapy visit: |
- Out-of-network: $40 copay
|
Outpatient individual therapy visit: |
- Out-of-network: $40 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: $15-40 copay depending on the service
|
Occupational therapy visit:- In-network: $15-40 copay depending on the service
|
- Out-of-network: $15-40 copay depending on the service
|
Physical therapy and speech and language therapy visit:- In-network: $15-40 copay depending on the service
|
- Out-of-network: $15-40 copay depending on the service
|
Outpatient substance abuse |
Group therapy visit:- In-network: $40-105 copay depending on the service
|
- Out-of-network: $40-105 copay depending on the service
|
Individual therapy visit:- In-network: $40-105 copay depending on the service
|
- Out-of-network: $40-105 copay depending on the service
|
Outpatient surgery |
Ambulatory surgical center: |
- Out-of-network: $245 copay
|
Outpatient hospital: |
- Out-of-network: $295 copay
|
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: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: 20% 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 |
$15-45 copay depending on the service |
Vision services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):- In-network: $0-45 copay depending on the service
|
- Out-of-network: $0-105 copay depending on the service
|
Eyeglasses or contact lenses after cataract surgery: |
- Out-of-network: $25 copay
|
** 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 |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
|
In-network: |
$295 copay per day for days 1 through 6 |
You pay nothing per day for days 7 through 90 |
You pay nothing per day for days 91 and beyond |
|
|
Out-of-network: |
$295 copay per day for days 1 through 6 |
You pay nothing per day for days 7 through 90 |
|
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 |
$160 copay per day for days 21 through 100 |
|
|
Out-of-network: |
You pay nothing per day for days 1 through 20 |
$160 copay per day for days 21 through 100 |
|
Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Other Part B drugs:- 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: 0-20% of the cost depending on the supply
|
- 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: 20% 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: $45 copay or 20% of the cost depending on the service
|
Hearing services |
Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: $45 copay or 20% of the cost depending on the service
|
** Outpatient Medical Services and Supplies ** |
Outpatient substance abuse |
Group therapy visit:- In-network: $40-105 copay depending on the service
|
- Out-of-network: $40-105 copay depending on the service
|
Individual therapy visit:- In-network: $40-105 copay depending on the service
|
- Out-of-network: $40-105 copay depending on the service
|
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: 20% 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: MyOption Plus |
Benefits include:- Preventive Dental
- Comprehensive Dental
- Eye Exams
- Eyewear
|
Additional $20.90 per month. You must keep paying your Medicare Part B premium and your $25 monthly plan premium. |
$50 per year. |
Our plan has a coverage limit for certain benefits. |
** Important Information ** |
Package 1: MyOption Plus |
Benefits include:- Preventive Dental
- Comprehensive Dental
- Eye Exams
- Eyewear
|
Additional $20.90 per month. You must keep paying your Medicare Part B premium and your $25 monthly plan premium. |
$50 per year. |
Our plan has a coverage limit for certain benefits. |
** Cost ** |
Package 2: MyOption Platinum Dental |
Benefits include:- Preventive Dental
- Comprehensive Dental
|
Additional $29.10 per month. You must keep paying your Medicare Part B premium and your $25 monthly plan premium. |
This package does not have a deductible. |
Our plan pays up to $2 000 every year. Our plan has additional coverage limits for certain benefits. |
** Important Information ** |
Package 2: MyOption Platinum Dental |
Benefits include:- Preventive Dental
- Comprehensive Dental
|
Additional $29.10 per month. You must keep paying your Medicare Part B premium and your $25 monthly plan premium. |
This package does not have a deductible. |
Our plan pays up to $2 000 every year. Our plan has additional coverage limits for certain benefits. |