** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$136.00 per month. In addition you must keep paying your Medicare Part B premium. |
This plan does not have a deductible. |
No. This plan does not have any limits. |
No. There are no limits on how much our plan will pay. |
** 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: You pay nothing |
Other Part B drugs: You pay nothing |
Our plan does not cover Part D prescription drug. |
** Important Information ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$136.00 per month. In addition you must keep paying your Medicare Part B premium. |
This plan does not have a deductible. |
No. This plan does not have any limits. |
No. There are no limits on how much our plan will pay. |
** Outpatient Care and Services ** |
Acupuncture |
Not covered |
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 |
Routine chiropractic visit: 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 |
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 |
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 6 visit(s) every year): You pay nothing |
Hearing services |
Exam to diagnose and treat hearing and balance issues: You pay nothing |
Routine hearing exam (for up to 1 every year): You pay nothing |
Home health 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 |
Physical therapy and speech and language therapy visit: 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 |
Over-the-counter items |
Not Covered |
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices: You pay nothing |
Related 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 |
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. |
** Inpatient Care ** |
Inpatient hospital care |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
You pay nothing |
Inpatient mental health care |
For inpatient mental health care see the "Mental Health Care" section. |
Skilled Nursing Facility (SNF) |
Our plan covers 130 days in a SNF. |
You pay nothing |
Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs: You pay nothing |
Other Part B drugs: You pay nothing |
Our plan does not cover Part D prescription drug. |
** 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 6 visit(s) every year): You pay nothing |
Hearing services |
Exam to diagnose and treat hearing and balance issues: You pay nothing |
Routine hearing exam (for up to 1 every year): 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 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: Out of Network Benefit |
Benefits include: |
Additional $20 per month. You must keep paying your Medicare Part B premium and your $136 monthly plan premium. |
This package does not have a deductible. |
No. There is no limit to how much our plan will pay for benefits in this package. |
** Important Information ** |
Package 1: Out of Network Benefit |
Benefits include: |
Additional $20 per month. You must keep paying your Medicare Part B premium and your $136 monthly plan premium. |
This package does not have a deductible. |
No. There is no limit to how much our plan will pay for benefits in this package. |