** Base Plan ** |
Premium |
• Health plan premium: $0 |
• Drug plan premium: $0 |
• You must continue to pay your Part B premium. |
• Part B premium reduction: No |
Deductible |
• Health plan deductible: $0 |
• Other health plan deductibles: In-network: No |
• Drug plan deductible: $175.00 annual deductible |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) |
• $10,000 In and Out-of-network $4,900 In-network |
Optional supplemental benefits |
• No |
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? |
• In-network: No |
Doctor visits |
• Primary In-network: $5 copay per visit |
• Primary Out-of-network: $45 copay per visit |
• Specialist In-network: $35 copay per visit (authorization required) |
• Specialist Out-of-network: $70 copay per visit (authorization required) |
Diagnostic procedures/lab services/imaging |
• Diagnostic tests and procedures In-network: $20 copay (authorization required) |
• Diagnostic tests and procedures Out-of-network: 40% coinsurance (authorization required) |
• Lab services In-network: $0 copay (authorization required) |
• Lab services Out-of-network: $0 copay (authorization required) |
• Diagnostic radiology services (e.g., MRI) In-network: $0-110 copay (authorization required) |
• Diagnostic radiology services (e.g., MRI) Out-of-network: 40% coinsurance (authorization required) |
• Outpatient x-rays In-network: $14 copay (authorization required) |
• Outpatient x-rays Out-of-network: $21 copay (authorization required) |
Emergency care/Urgent care |
• Emergency: $90 copay per visit (always covered) |
• Urgent care: $30-40 copay per visit (always covered) |
Inpatient hospital coverage |
• In-network: $270 per day for days 1 through 8 $0 per day for days 9 through 90 $0 per day for days 91 and beyond (authorization required) |
• Out-of-network: 40% per stay (authorization required) |
Outpatient hospital coverage |
• In-network: $0-270 copay per visit (authorization required) |
• Out-of-network: 40% coinsurance per visit (authorization required) |
Skilled Nursing Facility |
• In-network: $0 per day for days 1 through 20 $160 per day for days 21 through 51 $0 per day for days 52 through 100 (authorization required) |
• Out-of-network: $195 per day for days 1 through 52 $0 per day for days 53 through 100 (authorization required) |
Preventive care |
• In-network: $0 copay |
• Out-of-network: 0-40% coinsurance |
Ground ambulance |
• In-network: $250 copay |
• Out-of-network: $250 copay |
Rehabilitation services |
• Occupational therapy visit In-network: $35 copay (authorization required) |
• Occupational therapy visit Out-of-network: $70 copay (authorization required) |
• Physical therapy and speech and language therapy visit In-network: $35 copay (authorization required) |
• Physical therapy and speech and language therapy visit Out-of-network: $70 copay (authorization required) |
Mental health services |
• Inpatient hospital - psychiatric In-network: $270 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) |
• Inpatient hospital - psychiatric Out-of-network: 40% per stay (authorization required) |
• Outpatient group therapy visit with a psychiatrist In-network: $30 copay (authorization required) |
• Outpatient group therapy visit with a psychiatrist Out-of-network: $35-45 copay (authorization required) |
• Outpatient individual therapy visit with a psychiatrist In-network: $40 copay (authorization required) |
• Outpatient individual therapy visit with a psychiatrist Out-of-network: $35-45 copay (authorization required) |
• Outpatient group therapy visit In-network: $30 copay (authorization required) |
• Outpatient group therapy visit Out-of-network: $35-45 copay (authorization required) |
• Outpatient individual therapy visit In-network: $40 copay (authorization required) |
• Outpatient individual therapy visit Out-of-network: $35-45 copay (authorization required) |
Opioid treatment program services |
• In-network: $0.00 copay |
• Out-of-network: 40% coinsurance |
Medical equipment/supplies |
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required) |
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 50% coinsurance per item (authorization required) |
• Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required) |
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 40% coinsurance per item (authorization required) |
• Diabetes supplies In-network: $0 copay per item (authorization required) |
• Diabetes supplies Out-of-network: 40% coinsurance per item (authorization required) |
Dialysis |
• 20% coinsurance (authorization required) |
Hearing |
• Hearing exam In-network: $0 copay (authorization required) |
• Hearing exam Out-of-network: $70 copay (authorization required) |
• Fitting/evaluation: Not covered |
• Hearing aids In-network: $375-2,075 copay (limits apply, authorization required) |
• Hearing aids Out-of-network: $375 copay (limits apply, authorization required) |
Preventive dental |
• Oral exam In-network: $0 copay (limits apply) |
• Oral exam Out-of-network: $40 copay (limits apply) |
• Cleaning In-network: $0 copay (limits apply) |
• Cleaning Out-of-network: $40 copay (limits apply) |
• Fluoride treatment: Not covered |
• Dental x-ray(s) In-network: $0 copay (limits apply) |
• Dental x-ray(s) Out-of-network: $40 copay (limits apply) |
Comprehensive dental |
• Non-routine services: Not covered |
• Diagnostic services: Not covered |
• Restorative services: Not covered |
• Endodontics: Not covered |
• Periodontics: Not covered |
• Extractions: Not covered |
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered |
Vision |
• Routine eye exam In-network: $0 copay (limits apply, authorization required) |
• Routine eye exam Out-of-network: $70 copay (limits apply, authorization required) |
• Other: Not covered |
• Contact lenses: Not covered |
• Eyeglasses (frames and lenses): Not covered |
• Eyeglass frames: Not covered |
• Eyeglass lenses: Not covered |
• Upgrades: Not covered |
Wellness programs (e.g., fitness, nursing hotline) |
• Covered |
Transportation |
• Not covered |
Foot care (podiatry services) |
• Foot exams and treatment In-network: $35 copay (authorization required) |
• Foot exams and treatment Out-of-network: $70 copay (authorization required) |
• Routine foot care In-network: $35 copay (limits apply, authorization required) |
• Routine foot care Out-of-network: $70 copay (limits apply, authorization required) |
Medicare Part B drugs |
• Chemotherapy In-network: 20% coinsurance (authorization required) |
• Chemotherapy Out-of-network: 50% coinsurance (authorization required) |
• Other Part B drugs In-network: 20% coinsurance (authorization required) |
• Other Part B drugs Out-of-network: 50% coinsurance (authorization required) |
Medically-approved non-opioid pain management services |
• Chiropractic services: Not covered |
• Acupuncture: Not covered |
• Therapeutic Massage: Not covered |
• Alternative Therapies: Not covered |
More benefits |
• Over-the-counter drug benefits: Some coverage |
• Meals for short duration: Not covered |
• Annual physical exams: Some coverage |
• Telehealth: Some coverage |
• WorldWide emergency transportation: Some coverage |
• WorldWide emergency coverage: Some coverage |
• WorldWide emergency urgent care: Some coverage |
• Fitness Benefit: Some coverage |
• In-Home Support Services: Not covered |
• Bathroom Safety Devices: Not covered |
• Health Education: Not covered |
• In-Home Safety Assessment: Not covered |
• Personal Emergency Response System (PERS): Not covered |
• Medical Nutrition Therapy (MNT): Not covered |
• Post discharge In-Home Medication Reconciliation: Not covered |
• Re-admission Prevention: Not covered |
• Wigs for Hair Loss Related to Chemotherapy: Not covered |
• Weight Management Programs: Not covered |
• Adult Day Health Services: Not covered |
• Nutritional/Dietary Benefit: Not covered |
• Home-Based Palliative Care: Not covered |
• Support for Caregivers of Enrollees: Not covered |
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered |
• Enhanced Disease Management: Not covered |
• Telemonitoring Services: Not covered |
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage |
• Counseling Services: Not covered |