** 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 |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) |
• $3,000 In-network |
Optional supplemental benefits |
• No |
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? |
• In-network: Yes, contact plan for further details |
Doctor visits |
• Primary: $0 copay |
• Specialist: $40 copay per visit |
Diagnostic procedures/lab services/imaging |
• Diagnostic tests and procedures: $0-100 copay (authorization and referral required) |
• Lab services: $5 copay (authorization and referral required) |
• Diagnostic radiology services (e.g., MRI): $0-250 copay (authorization and referral required) |
• Outpatient x-rays: $0 copay (authorization and referral required) |
Emergency care/Urgent care |
• Emergency: $120 copay per visit (always covered) |
• Urgent care: $15 copay per visit (always covered) |
Inpatient hospital coverage |
• $400 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization and referral required) |
Outpatient hospital coverage |
• $15-320 copay per visit (authorization and referral required) |
Skilled Nursing Facility |
• $0 per day for days 1 through 20 $184 per day for days 21 through 100 (authorization and referral required) |
Preventive care |
• $0 copay |
Ground ambulance |
• $250 copay |
Rehabilitation services |
• Occupational therapy visit: $20 copay (authorization and referral required) |
• Physical therapy and speech and language therapy visit: $20 copay (authorization and referral required) |
Mental health services |
• Inpatient hospital - psychiatric: $275 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization and referral required) |
• Outpatient group therapy visit with a psychiatrist: $0 copay |
• Outpatient individual therapy visit with a psychiatrist: $0 copay |
• Outpatient group therapy visit: $0 copay |
• Outpatient individual therapy visit: $0 copay |
Medical equipment/supplies |
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required) |
• Prosthetics (e.g., braces, artificial limbs): 0-20% coinsurance per item (authorization required) |
• Diabetes supplies: $0 copay (authorization required) |
Hearing |
• Hearing exam: $0-40 copay |
• Fitting/evaluation: $0 copay (limits apply) |
• Hearing aids: $0 copay (limits apply) |
Preventive dental |
• Oral exam: $0 copay (limits apply) |
• Cleaning: $0 copay (limits apply) |
• Fluoride treatment: Not covered |
• Dental x-ray(s): $0 copay (limits apply) |
Comprehensive dental |
• Non-routine services: $0 copay (limits apply, authorization and referral required) |
• Diagnostic services: $0 copay (limits apply, authorization and referral required) |
• Restorative services: $0 copay (limits apply, authorization and referral required) |
• Endodontics: $0 copay (limits apply, authorization and referral required) |
• Periodontics: $0 copay (limits apply, authorization and referral required) |
• Extractions: $0 copay (limits apply, authorization and referral required) |
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay (limits apply, authorization and referral required) |
Vision |
• Routine eye exam: $0 copay (limits apply) |
• Other: Not covered |
• Contact lenses: $0 copay (limits apply) |
• Eyeglasses (frames and lenses): $0 copay (limits apply) |
• Eyeglass frames: Not covered |
• Eyeglass lenses: Not covered |
• Upgrades: Not covered |
Wellness programs (e.g., fitness, nursing hotline) |
• Covered (authorization and referral required) |
Transportation |
• Not covered |
Foot care (podiatry services) |
• Foot exams and treatment: $40 copay |
• Routine foot care: Not covered |
Medicare Part B drugs |
• Chemotherapy: 20% coinsurance (authorization required) |
• Other Part B drugs: 20% coinsurance (authorization required) |