** 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: $500 annual deductible |
• Other health plan deductibles: In-network: No |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) |
• $11,300 In and Out-of-network $6,700 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: $15 copay per visit |
• Primary Out-of-network: 30% coinsurance per visit |
• Specialist In-network: $50 copay per visit |
• Specialist Out-of-network: 30% coinsurance per visit |
Diagnostic procedures/lab services/imaging |
• Diagnostic tests and procedures In-network: $0-100 copay (authorization required) |
• Diagnostic tests and procedures Out-of-network: $0 copay or 30% coinsurance (authorization required) |
• Lab services In-network: $0-50 copay (authorization required) |
• Lab services Out-of-network: 30% coinsurance (authorization required) |
• Diagnostic radiology services (e.g., MRI) In-network: $50-245 copay (authorization required) |
• Diagnostic radiology services (e.g., MRI) Out-of-network: 30% coinsurance (authorization required) |
• Outpatient x-rays In-network: $15-100 copay (authorization required) |
• Outpatient x-rays Out-of-network: 30% coinsurance (authorization required) |
Emergency care/Urgent care |
• Emergency: $90 copay per visit (always covered) |
• Urgent care: $15-50 copay or 30% coinsurance per visit (always covered) |
Inpatient hospital coverage |
• In-network: $245 per day for days 1 through 6 $0 per day for days 7 through 90 $0 per day for days 91 and beyond (authorization required) |
• Out-of-network: 30% per stay (authorization required) |
Outpatient hospital coverage |
• In-network: $50-245 copay per visit (authorization required) |
• Out-of-network: 30% coinsurance per visit (authorization required) |
Skilled Nursing Facility |
• In-network: $0 per day for days 1 through 20 $172 per day for days 21 through 100 (authorization required) |
• Out-of-network: 30% per stay (authorization required) |
Preventive care |
• In-network: $0 copay |
• Out-of-network: $0 copay or 30% coinsurance |
Ground ambulance |
• In-network: $265 copay |
• Out-of-network: $265 copay |
Rehabilitation services |
• Occupational therapy visit In-network: $15-40 copay (authorization required) |
• Occupational therapy visit Out-of-network: 30% coinsurance (authorization required) |
• Physical therapy and speech and language therapy visit In-network: $15-40 copay (authorization required) |
• Physical therapy and speech and language therapy visit Out-of-network: 30% coinsurance (authorization required) |
Mental health services |
• Inpatient hospital - psychiatric In-network: $245 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) |
• Inpatient hospital - psychiatric Out-of-network: 30% per stay (authorization required) |
• Outpatient group therapy visit with a psychiatrist In-network: $40 copay (authorization required) |
• Outpatient group therapy visit with a psychiatrist Out-of-network: 30% coinsurance (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: 30% coinsurance (authorization required) |
• Outpatient group therapy visit In-network: $40 copay (authorization required) |
• Outpatient group therapy visit Out-of-network: 30% coinsurance (authorization required) |
• Outpatient individual therapy visit In-network: $40 copay (authorization required) |
• Outpatient individual therapy visit Out-of-network: 30% coinsurance (authorization required) |
Medical equipment/supplies |
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 15% coinsurance per item (authorization required) |
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 20% coinsurance per item (authorization required) |
• Prosthetics (e.g., braces, artificial limbs) In-network: 15% coinsurance per item (authorization required) |
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 20% coinsurance per item (authorization required) |
• Diabetes supplies In-network: $0 copay or 10-20% coinsurance per item (authorization required) |
• Diabetes supplies Out-of-network: 30% coinsurance per item (authorization required) |
Hearing |
• Hearing exam In-network: $50 copay (authorization required) |
• Hearing exam Out-of-network: 30% coinsurance (authorization required) |
• Fitting/evaluation In-network: $0 copay (limits apply, authorization required) |
• Fitting/evaluation Out-of-network: $0 copay (limits apply, authorization required) |
• Hearing aids In-network: $699-999 copay (limits apply) |
• Hearing aids Out-of-network: $699-999 copay (limits apply) |
Preventive dental |
• Oral exam In-network: $0 copay (limits apply) |
• Oral exam Out-of-network: 50% coinsurance (limits apply) |
• Cleaning In-network: $0 copay (limits apply) |
• Cleaning Out-of-network: 50% coinsurance (limits apply) |
• Fluoride treatment In-network: $0 copay (limits apply) |
• Fluoride treatment Out-of-network: 50% coinsurance (limits apply) |
• Dental x-ray(s) In-network: $0 copay (limits apply) |
• Dental x-ray(s) Out-of-network: 50% coinsurance (limits apply) |
Comprehensive dental |
• Non-routine services: Not covered |
• Diagnostic services: Not covered |
• Restorative services In-network: 50% coinsurance (limits apply, authorization required) |
• Restorative services Out-of-network: 55-75% coinsurance (limits apply, authorization required) |
• Endodontics: Not covered |
• Periodontics In-network: 70% coinsurance (limits apply, authorization required) |
• Periodontics Out-of-network: 55-75% coinsurance (limits apply, authorization required) |
• Extractions In-network: 50% coinsurance (limits apply, authorization required) |
• Extractions Out-of-network: 55-75% coinsurance (limits apply, authorization required) |
• 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: $0 copay (limits apply, authorization required) |
• Other: Not covered |
• Contact lenses In-network: $0 copay (limits apply, authorization required) |
• Contact lenses Out-of-network: $0 copay (limits apply, authorization required) |
• Eyeglasses (frames and lenses) In-network: $0 copay (limits apply, authorization required) |
• Eyeglasses (frames and lenses) Out-of-network: $0 copay (limits apply, authorization required) |
• Eyeglass frames: Not covered |
• Eyeglass lenses: Not covered |
• Upgrades: Not covered |
Wellness programs (e.g., fitness, nursing hotline) |
• Covered (authorization required) |
Transportation |
• Not covered |
Foot care (podiatry services) |
• Foot exams and treatment In-network: $50 copay (authorization required) |
• Foot exams and treatment Out-of-network: 30% coinsurance (authorization required) |
• Routine foot care: Not covered |
Medicare Part B drugs |
• Chemotherapy In-network: 20% coinsurance (authorization required) |
• Chemotherapy Out-of-network: 30% coinsurance (authorization required) |
• Other Part B drugs In-network: 20% coinsurance (authorization required) |
• Other Part B drugs Out-of-network: 30% coinsurance (authorization required) |