** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$180 per month. In addition you must keep paying your Medicare Part B premium. |
This plan does not have a deductible. |
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: |
- $225 for services you receive from in-network providers.
|
- $3 400 for services you receive from out-of-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. 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:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Other Part B drugs1:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
You pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Standard Retail Cost-Sharing Tier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $2 copay | $4 copay | $6 copay | Tier 2 (Generic) | $5 copay | $10 copay | $15 copay | Tier 3 (Preferred Brand) | $39 copay | $78 copay | $117 copay | Tier 4 (Non-Preferred Brand) | $75 copay | $150 copay | $225 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | |
Preferred Retail Cost-Sharing Tier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | $0 | $0 | Tier 2 (Generic) | $0 | $0 | $0 | Tier 3 (Preferred Brand) | $34 copay | $68 copay | $102 copay | Tier 4 (Non-Preferred Brand) | $65 copay | $130 copay | $195 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | |
Standard Mail Order Cost-Sharing Tier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $2 copay | $4 copay | $6 copay | Tier 2 (Generic) | $5 copay | $10 copay | $15 copay | Tier 3 (Preferred Brand) | $39 copay | $78 copay | $117 copay | Tier 4 (Non-Preferred Brand) | $75 copay | $150 copay | $225 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | |
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.
|
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap. |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of: - $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
|
** Important Information ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$180 per month. In addition you must keep paying your Medicare Part B premium. |
This plan does not have a deductible. |
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: |
- $225 for services you receive from in-network providers.
|
- $3 400 for services you receive from out-of-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. 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 |
- 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: 20% of the cost
|
Dental services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): |
A single office visit that includes: |
- Cleaning (for up to 2 every year)
|
- Dental x-ray(s) (for up to 1 every year)
|
- Fluoride treatment (for up to 1 every year)
|
- Oral exam (for up to 2 every year)
|
Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- 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: You pay nothing
|
- Out-of-network: 20% of the cost
|
Diagnostic tests and procedures:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Lab services:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Outpatient x-rays:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Doctor's office visits |
Primary care physician visit:- In-network: You pay nothing
|
Specialist visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Durable medical equipment (wheelchairs, oxygen, etc.) |
- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Emergency care |
$75 copay |
If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs. |
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: 20% of the cost
|
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. You are covered for up to 1 every year.
|
Hearing aid:- In-network: You pay nothing
|
Our plan pays up to $2 000 every three years for hearing aids from an in-network provider. |
Home health care |
- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
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: |
20% of the cost per stay |
|
Outpatient group therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Outpatient individual therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
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
|
- Out-of-network: 20% of the cost
|
Occupational therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Physical therapy and speech and language therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Outpatient substance abuse |
Group therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Individual therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Outpatient surgery |
Ambulatory surgical center:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Outpatient hospital:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Over-the-counter items |
Not Covered |
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Renal dialysis |
- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
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: $35 copay. You are covered for up to 1 every year.
|
Our plan pays up to $175 every year for contact lenses from an in-network provider. |
Eyeglass frames:- In-network: $35 copay. You are covered for up to 1 every year.
|
Our plan pays up to $150 every year for eyeglass frames from an in-network provider. |
Eyeglass lenses:- In-network: You pay nothing. You are covered for up to 1 every year.
|
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. |
** 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: |
20% of the cost per stay |
|
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
|
|
Out-of-network: |
20% of the cost per stay |
|
Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs1:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Other Part B drugs1:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
You pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Standard Retail Cost-Sharing Tier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $2 copay | $4 copay | $6 copay | Tier 2 (Generic) | $5 copay | $10 copay | $15 copay | Tier 3 (Preferred Brand) | $39 copay | $78 copay | $117 copay | Tier 4 (Non-Preferred Brand) | $75 copay | $150 copay | $225 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | |
Preferred Retail Cost-Sharing Tier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $0 | $0 | $0 | Tier 2 (Generic) | $0 | $0 | $0 | Tier 3 (Preferred Brand) | $34 copay | $68 copay | $102 copay | Tier 4 (Non-Preferred Brand) | $65 copay | $130 copay | $195 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | |
Standard Mail Order Cost-Sharing Tier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | $2 copay | $4 copay | $6 copay | Tier 2 (Generic) | $5 copay | $10 copay | $15 copay | Tier 3 (Preferred Brand) | $39 copay | $78 copay | $117 copay | Tier 4 (Non-Preferred Brand) | $75 copay | $150 copay | $225 copay | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | |
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.
|
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap. |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of: - $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
|
** Outpatient Care ** |
Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- 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:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
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. You are covered for up to 1 every year.
|
Hearing aid:- In-network: You pay nothing
|
Our plan pays up to $2 000 every three years for hearing aids from an in-network provider. |
** Outpatient Medical Services and Supplies ** |
Outpatient substance abuse |
Group therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Individual therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
** Additional Benefits ** |
Inpatient mental health care |
For inpatient mental health care see the "Mental Health Care" section. |