** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$0 per month. In addition you must keep paying your Medicare Part B premium. |
$0 to $74 per year 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: |
- $6 700 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: 0% or 20% of the cost |
Other Part B drugs1: 0% or 20% of the cost |
Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay. |
You may get your drugs at network retail pharmacies. |
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 at the same cost as an in-network pharmacy.
|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay nothing for all drugs. |
** Important Information ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$0 per month. In addition you must keep paying your Medicare Part B premium. |
$0 to $74 per year 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: |
- $6 700 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 |
$0 or $200 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): $0 or $20 copay |
Dental services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): $0 or $35 copay |
Preventive dental services: |
Cleaning (for up to 1 every six months): You pay nothing |
Dental x-ray(s) (for up to 1 every six months): You pay nothing |
Oral exam (for up to 1 every six months): You pay nothing |
Diabetes supplies and services |
Diabetes monitoring supplies: 0% or 20% of the cost |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: 0% or 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): $0 or $35-175 copay depending on the service |
Diagnostic tests and procedures: You pay nothing |
Lab services: You pay nothing |
Outpatient x-rays: $0 or $35 copay |
Therapeutic radiology services (such as radiation treatment for cancer): $0 or $60 copay |
Doctor's office visits |
Primary care physician visit: You pay nothing |
Specialist visit: $0 or $35 copay |
Durable medical equipment (wheelchairs, oxygen, etc.) |
0% or 20% of the cost |
Emergency care |
$0 or $75 copay |
Foot care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $0 or $35 copay |
Routine foot care: $35 copay |
Hearing services |
Exam to diagnose and treat hearing and balance issues: You pay nothing |
Routine hearing exam: You pay nothing |
Hearing aid fitting/evaluation: You pay nothing |
Hearing aid: You pay nothing |
Our plan pays up to $750 every two years for hearing aids. |
Home health care |
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. |
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. |
|
$0 or $275 copay per day for days 1 through 5 |
You pay nothing per day for days 6 through 90 |
|
Outpatient group therapy visit: $0 or $35 copay |
Outpatient individual therapy visit: $0 or $35 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): $0 or $35 copay |
Occupational therapy visit: $0 or $35 copay |
Physical therapy and speech and language therapy visit: $0 or $35 copay |
Outpatient substance abuse |
Group therapy visit: $0 or $35 copay |
Individual therapy visit: $0 or $35 copay |
Outpatient surgery |
Ambulatory surgical center: $0 or $200 copay |
Outpatient hospital: $0 or $200-275 copay 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: 0% or 20% of the cost |
Related medical supplies: 0% or 20% of the cost |
Renal dialysis |
0% or 20% of the cost |
Transportation |
You pay nothing |
Urgently needed services |
$0 or $45 copay |
Vision services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0 or $35 copay |
Routine eye exam (for up to 1 every three months): You pay nothing |
Contact lenses (for up to 1 every year): You pay nothing |
Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing |
Eyeglasses or contact lenses after cataract surgery: You pay nothing |
Our plan pays up to $100 every year for contact lenses and eyeglasses (frames and lenses). |
** 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 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. |
|
$0 or $275 copay per day for days 1 through 5 |
You pay nothing per day for days 6 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. |
|
You pay nothing per day for days 1 through 20 |
$0 or $160 copay per day for days 21 through 100 |
|
Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs1: 0% or 20% of the cost |
Other Part B drugs1: 0% or 20% of the cost |
Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay. |
You may get your drugs at network retail pharmacies. |
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 at the same cost as an in-network pharmacy.
|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay nothing for all drugs. |
** Outpatient Care ** |
Diabetes supplies and services |
Diabetes monitoring supplies: 0% or 20% of the cost |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: 0% or 20% of the cost |
Foot care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $0 or $35 copay |
Routine foot care: $35 copay |
Hearing services |
Exam to diagnose and treat hearing and balance issues: You pay nothing |
Routine hearing exam: You pay nothing |
Hearing aid fitting/evaluation: You pay nothing |
Hearing aid: You pay nothing |
Our plan pays up to $750 every two years for hearing aids. |
** Outpatient Medical Services and Supplies ** |
Outpatient substance abuse |
Group therapy visit: $0 or $35 copay |
Individual therapy visit: $0 or $35 copay |
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices: 0% or 20% of the cost |
Related medical supplies: 0% or 20% of the cost |
** Additional Benefits ** |
Inpatient mental health care |
For inpatient mental health care see the "Mental Health Care" section. |