** 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: You pay nothing |
Other Part B drugs1: You pay nothing |
You may get your drugs at network retail pharmacies and mail order pharmacies. |
You pay nothing |
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 nothing |
Institutional care |
Institution for mental disease services for individuals 65 or older: You pay nothing |
Nursing home services: 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: You pay nothing |
Self-directed personal assistance services: You pay nothing |
Additional services |
Nursing Services for Waiver Clients: You pay nothing |
Minor Home Modifications for Waiver Clients: You pay nothing (there is a limit to how much our plan will pay) |
Emergency Response Services for Waiver Clients: You pay nothing |
Assisted Living Services for Waiver Clients: You pay nothing |
Adult Foster Care for Waiver Clients: You pay nothing |
Transitional Assistance Services for Waiver Clients: You pay nothing (there is a limit to how much our plan will pay) |
Respite Care for Waiver Clients (for up to 30 visits every year): You pay nothing |
Behavioral Health Care Services: You pay nothing |
Employment Assistance for Waiver Clients: You pay nothing |
Supported Employment for Waiver Clients: You pay nothing |
Cognitive Rehabilitation Therapy for Waiver Clients: You pay nothing |
Adaptive Aids and Medical Supplies for Waiver Clients: You pay nothing (there is a limit to how much our plan will pay) |
Home-Delivered Meals for Waiver Clients: You pay nothing |
Personal Assistance Services: You pay nothing |
Dental Services for Waiver Clients: You pay nothing (there is a limit to how much our plan will pay) |
Occupational Therapy for Waiver Clients: You pay nothing |
Speech Hearing and Language Therapy for Waiver Clients: You pay nothing |
Support Consultation for Waiver Clients: You pay nothing |
Habilitation Services: You pay nothing |
Emergency Response Services: You pay nothing |
Home Visits: You pay nothing |
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 |
Dental services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing |
Preventive dental services: |
Cleaning (for up to 2 every year): You pay nothing |
Dental x-ray(s) (for up to 1 every year): You pay nothing |
Fluoride treatment (for up to 1 every year): You pay nothing |
Oral exam (for up to 2 every year): You pay nothing |
Our plan pays up to $1 000 every year for most dental services. |
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 |
Durable medical equipment for use outside the home: 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 12 visit(s) every year): You pay nothing |
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 |
Home health care |
You pay nothing |
Additional hours of care: You pay nothing |
Mental health care |
Inpatient visit: |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
You pay nothing |
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 |
Additional Occupational Therapy Services: You pay nothing |
Physical therapy and speech and language therapy visit: You pay nothing |
Additional Physical Therapy Services: You pay nothing |
Additional Speech Hearing & Language Therapy Services: 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 |
Freestanding birth center services: 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: You pay nothing |
Related medical supplies: You pay nothing |
Additional 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 |
Contact lenses (for up to 1 every two years): You pay nothing |
Eyeglasses (frames and lenses) (for up to 1 every two years): 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. |
Family planning services: You pay nothing |
Tobacco cessation counseling for pregnant women: You pay nothing |
** Inpatient Care ** |
Inpatient hospital care |
Our plan covers 120 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 120 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 120 days. |
You pay nothing |
Inpatient mental health care |
For inpatient mental health care see the "Mental Health Care" section. |
Institutional care |
Institution for mental disease services for individuals 65 or older: You pay nothing |
Nursing home services: You pay nothing |
Skilled Nursing Facility (SNF) |
Our plan covers an unlimited number of 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 |
You may get your drugs at network retail pharmacies and mail order pharmacies. |
You pay nothing |
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 nothing |
Additional home care services |
Home and community based services: You pay nothing |
Self-directed personal assistance services: You pay nothing |
** 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 12 visit(s) every year): You pay nothing |
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 |
** 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 Medical Supplies: You pay nothing |
** Additional Benefits ** |
Inpatient mental health care |
For inpatient mental health care see the "Mental Health Care" section. |
Institutional care |
Institution for mental disease services for individuals 65 or older: You pay nothing |
Nursing home services: You pay nothing |