** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
You pay nothing |
You pay nothing |
In this plan you will pay nothing for services from any provider. |
Please note that you will still need to pay your 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:- In-network: You pay nothing
|
Other Part B drugs1:- In-network: You pay nothing
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
You pay the following: |
Standard Retail Cost-Sharing Tier | Your cost |
---|
Tier 1 (Generic Drugs) | $0 | Tier 2 (Brand Drugs) | $0 | Tier 3 (Non-Medicare Rx Drugs) | $0 | Tier 4 (Non-Medicare OTC Drugs) | $0 | |
Standard Mail Order Cost-Sharing Tier | Your cost |
---|
Tier 1 (Generic Drugs) | $0 | Tier 2 (Brand Drugs) | $0 | Tier 3 (Non-Medicare Rx Drugs) | $0 | Tier 4 (Non-Medicare OTC Drugs) | $0 | |
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.
|
You pay the following: |
Tier | Your cost |
---|
Tier 1 (Generic Drugs) | $0 | Tier 2 (Brand Drugs) | $0 | Tier 3 (Non-Medicare Rx Drugs) | $0 | Tier 4 (Non-Medicare OTC Drugs) | $0 | |
Institutional care |
Case management (long term care): - In-network: You pay nothing
|
Nursing home services: - In-network: You pay nothing
|
** Important Information ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
You pay nothing |
You pay nothing |
In this plan you will pay nothing for services from any provider. |
Please note that you will still need to pay your 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 |
Additional home care services |
Home and community based services: - In-network: You pay nothing
|
Personal care services: - In-network: You pay nothing
|
Private duty nursing services: - In-network: You pay nothing
|
Self-directed personal assistance services: - In-network: You pay nothing
|
Additional services |
Case management: - In-network: You pay nothing
|
Adult Day Health Care AIDS Adult Day Health Care: - In-network: You pay nothing
|
Nutrition Wellness Counseling: - In-network: You pay nothing
|
Assertive Community Treatment Assisted Living Program: - In-network: You pay nothing
|
Outpatient Hospitalization Outpatient Surgery: - In-network: You pay nothing
|
Community Integration Counseling Community Transition Services: - In-network: You pay nothing
|
Day Treatment Continuing Day Treatment OMH Licensed CRs: - In-network: You pay nothing
|
Substance Abuse Prog. Opioid Treatment Svcs - Substance Abuse: - In-network: You pay nothing
|
Medication Therapy Managment: - In-network: You pay nothing
|
Medicare Pt A and B Services as Covered by Medicaid: - In-network: You pay nothing
|
Intensive Psychiatric Rehab. Svcs. Partial Hosp. (Medicaid): - In-network: You pay nothing
|
Home Maintenance Services Moving Assistance: - In-network: You pay nothing
|
Home Visits by Medical Personnel Respite Personal Emerg. Response Svcs: - In-network: You pay nothing
|
Independent Living Skills Training and Development: - In-network: You pay nothing
|
Peer-Delivered Services Peer Mentoring Mobile Mental Health: - In-network: You pay nothing
|
Home and Comm. Support Services Medical Social Services: - In-network: You pay nothing
|
Social Day Care Structured Day Program Soc. and Environmental Svcs.: - In-network: You pay nothing
|
Outpat. MH Outpat. SA Outpat. Med. Supervised Subst. Withdrawal - SA: - In-network: You pay nothing
|
Personalized Recovery Oriented Svcs. Pos. Behav. Interventions and Svcs: - In-network: You pay nothing
|
Comprehensive Psychiatric Emergency Program (CPEP): - In-network: You pay nothing
|
Crisis Intervention: - In-network: You pay nothing
|
Residential Addiction Services: - In-network: You pay nothing
|
Ambulance |
- In-network: You pay nothing
|
- Out-of-network: 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):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Dental services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):- In-network: You pay nothing
|
Preventive dental services: |
Cleaning:- In-network: You pay nothing. You are covered for up to 1 every six months.
|
Dental x-ray(s):- In-network: You pay nothing. You are covered for up to 1 every six months.
|
Oral exam:- In-network: You pay nothing. You are covered for up to 1 every six months.
|
Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 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):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Diagnostic tests and procedures:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Lab services:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Outpatient x-rays:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Doctor's office visits |
Primary care physician visit:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Specialist visit:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Durable medical equipment (wheelchairs, oxygen, etc.) |
- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Durable medical equipment for use outside the home:- In-network: You pay nothing
|
Environmental Modifications Adaptive Devices:- In-network: You pay nothing
|
Assistive Technology:- In-network: 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:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Routine foot care:- In-network: You pay nothing. You are covered for up to 4 every year.
|
Hearing services |
Exam to diagnose and treat hearing and balance issues:- In-network: You pay nothing
|
Routine hearing exam:- In-network: You pay nothing
|
Hearing aid fitting/evaluation:- In-network: You pay nothing
|
Hearing aid:- In-network: You pay nothing
|
Home health care |
- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Additional hours of care:- In-network: You pay nothing
|
Personal Care Services:- In-network: You pay nothing
|
Mental health care |
Inpatient visit: |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Outpatient group therapy visit:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Outpatient individual therapy visit:- In-network: You pay nothing
|
- Out-of-network: 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):- In-network: You pay nothing. Additional visits are covered but your cost may be more.
|
- Out-of-network: You pay nothing
|
Respiratory care services:- In-network: You pay nothing
|
Occupational therapy visit:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Medicaid Outpatient Rehabilitation:- In-network: You pay nothing
|
Physical therapy and speech and language therapy visit:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Medicaid PT and SLPS:- In-network: You pay nothing
|
Outpatient substance abuse |
Group therapy visit:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Individual therapy visit:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Outpatient surgery |
Ambulatory surgical center:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Outpatient hospital:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Freestanding birth center services:- In-network: You pay nothing
|
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: You pay nothing
|
- Out-of-network: You pay nothing
|
Related medical supplies:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Medicaid Prosthetics/Medical Supplies:- In-network: You pay nothing
|
Renal dialysis |
- In-network: You pay nothing
|
Transportation |
- In-network: You pay nothing
|
Urgently needed services |
You pay nothing |
Vision services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):- In-network: You pay nothing
|
Routine eye exam:- In-network: You pay nothing. You are covered for up to 1 visit(s) every year.
|
Contact lenses:- In-network: You pay nothing. You are covered for up to 1 every two years.
|
Eyeglasses (frames and lenses):- In-network: You pay nothing. You are covered for up to 1 every two years.
|
Eyeglasses or contact lenses after cataract surgery:- In-network: 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 |
- 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. |
Family planning services:- In-network: You pay nothing
|
Tobacco cessation counseling for pregnant women:- In-network: You pay nothing
|
** Inpatient Care ** |
Inpatient hospital care |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Inpatient mental health care |
For inpatient mental health care see the "Mental Health Care" section. |
Institutional care |
Case management (long term care): - In-network: You pay nothing
|
Nursing home services: - In-network: You pay nothing
|
Skilled Nursing Facility (SNF) |
Our plan covers an unlimited number of days in a SNF. |
- In-network: You pay nothing
|
Out-of-network: You pay nothing |
Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs1:- In-network: You pay nothing
|
Other Part B drugs1:- In-network: You pay nothing
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
You pay the following: |
Standard Retail Cost-Sharing Tier | Your cost |
---|
Tier 1 (Generic Drugs) | $0 | Tier 2 (Brand Drugs) | $0 | Tier 3 (Non-Medicare Rx Drugs) | $0 | Tier 4 (Non-Medicare OTC Drugs) | $0 | |
Standard Mail Order Cost-Sharing Tier | Your cost |
---|
Tier 1 (Generic Drugs) | $0 | Tier 2 (Brand Drugs) | $0 | Tier 3 (Non-Medicare Rx Drugs) | $0 | Tier 4 (Non-Medicare OTC Drugs) | $0 | |
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.
|
You pay the following: |
Tier | Your cost |
---|
Tier 1 (Generic Drugs) | $0 | Tier 2 (Brand Drugs) | $0 | Tier 3 (Non-Medicare Rx Drugs) | $0 | Tier 4 (Non-Medicare OTC Drugs) | $0 | |
Additional home care services |
Home and community based services: - In-network: You pay nothing
|
Personal care services: - In-network: You pay nothing
|
Private duty nursing services: - In-network: You pay nothing
|
Self-directed personal assistance services: - In-network: You pay nothing
|
** Outpatient Care ** |
Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Foot care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Routine foot care:- In-network: You pay nothing. You are covered for up to 4 every year.
|
Hearing services |
Exam to diagnose and treat hearing and balance issues:- In-network: You pay nothing
|
Routine hearing exam:- In-network: You pay nothing
|
Hearing aid fitting/evaluation:- In-network: You pay nothing
|
Hearing aid:- In-network: You pay nothing
|
** Outpatient Medical Services and Supplies ** |
Outpatient substance abuse |
Group therapy visit:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Individual therapy visit:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Related medical supplies:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Medicaid Prosthetics/Medical Supplies:- In-network: You pay nothing
|
** Additional Benefits ** |
Inpatient mental health care |
For inpatient mental health care see the "Mental Health Care" section. |
Institutional care |
Case management (long term care): - In-network: You pay nothing
|
Nursing home services: - In-network: You pay nothing
|