** Base Plan ** |
Premium |
• Total monthly premium: $134.00 |
• Health plan premium: $61.20 |
• Drug plan premium: $72.80 |
• You must continue to pay your Part B premium. |
• Part B premium reduction: No |
Deductible |
• Health plan deductible: $1 |
• Other health plan deductibles: In-network: No
|
• Drug plan deductible: $55.00 annual deductible |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) |
• $5 |
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: $0 copay
|
• Primary Out-of-network: 30% coinsurance per visit
|
• Specialist In-network: $30 copay per visit
(authorization required) |
• Specialist Out-of-network: 30% coinsurance per visit
(authorization required) |
Diagnostic procedures/lab services/imaging |
• Diagnostic tests and procedures In-network: $0-10 copay
(authorization required) |
• Diagnostic tests and procedures Out-of-network: 30% coinsurance
(authorization required) |
• Lab services In-network: $0-10 copay
(authorization required) |
• Lab services Out-of-network: 30% coinsurance
(authorization required) |
• Diagnostic radiology services (e.g., MRI) In-network: $100-175 copay
(authorization required) |
• Diagnostic radiology services (e.g., MRI) Out-of-network: 30% coinsurance
(authorization required) |
• Outpatient x-rays In-network: $50 copay
(authorization required) |
• Outpatient x-rays Out-of-network: 30% coinsurance
(authorization required) |
Emergency care/Urgent care |
• Emergency: $120 copay per visit (always covered)
|
• Urgent care: $30 copay per visit (always covered)
|
Inpatient hospital coverage |
• In-network: $375 per day for days 1 through 6 $0 per day for days 7 through 90
(authorization required) |
• Out-of-network: 30% per stay
(authorization required) |
Outpatient hospital coverage |
• In-network: $380 copay per visit
(authorization required) |
• Out-of-network: 30% coinsurance per visit
(authorization required) |
Skilled Nursing Facility |
• In-network: $20 per day for days 1 through 20 $188 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: 30% coinsurance
|
Ground ambulance |
• In-network: $200 copay
|
• Out-of-network: $200 copay
|
Rehabilitation services |
• Occupational therapy visit In-network: $40 copay
(authorization required) |
• Occupational therapy visit Out-of-network: 30% coinsurance
(authorization required) |
• Physical therapy and speech and language therapy visit In-network: $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: $370 per day for days 1 through 5 $0 per day for days 6 through 90
(authorization required) |
• Inpatient hospital - psychiatric Out-of-network: 30% per stay
(authorization required) |
• Outpatient group therapy visit with a psychiatrist In-network: $30 copay
|
• Outpatient group therapy visit with a psychiatrist Out-of-network: 30% coinsurance
|
• Outpatient individual therapy visit with a psychiatrist In-network: $30 copay
|
• Outpatient individual therapy visit with a psychiatrist Out-of-network: 30% coinsurance
|
• Outpatient group therapy visit In-network: $30 copay
|
• Outpatient group therapy visit Out-of-network: 30% coinsurance
|
• Outpatient individual therapy visit In-network: $30 copay
|
• Outpatient individual therapy visit Out-of-network: 30% coinsurance
|
Opioid treatment program services |
• In-network: 20% coinsurance or $0.00-$30.00 copay (authorization required) |
• Out-of-network: 30% coinsurance (authorization required) |
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: 30% 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: 30% coinsurance per item
(authorization required) |
• Diabetes supplies In-network: 0-20% coinsurance per item
|
• Diabetes supplies Out-of-network: 20% coinsurance per item
|
Dialysis |
• 20% coinsurance |
Hearing |
• Hearing exam In-network: $0 copay
|
• Hearing exam Out-of-network: 30% coinsurance
|
• Fitting/evaluation: Not covered
|
• 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: Not covered
|
• 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 In-network: 30% coinsurance
(limits apply) |
• Non-routine services Out-of-network: 55-70% coinsurance
(limits apply) |
• Diagnostic services In-network: 30% coinsurance
(limits apply) |
• Diagnostic services Out-of-network: 55-70% coinsurance
(limits apply) |
• Restorative services In-network: 30% coinsurance
(limits apply) |
• Restorative services Out-of-network: 55-70% coinsurance
(limits apply) |
• Endodontics In-network: 50% coinsurance
(limits apply) |
• Endodontics Out-of-network: 55-70% coinsurance
(limits apply) |
• Periodontics In-network: 50% coinsurance
(limits apply) |
• Periodontics Out-of-network: 55-70% coinsurance
(limits apply) |
• Extractions In-network: 30% coinsurance
(limits apply) |
• Extractions Out-of-network: 55-70% coinsurance
(limits apply) |
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
|
Vision |
• Routine eye exam In-network: $0 copay
(limits apply) |
• Routine eye exam Out-of-network: $50 copay
(limits apply) |
• Other: Not covered
|
• Contact lenses In-network: $0 copay
(limits apply) |
• Contact lenses Out-of-network: $0 copay
(limits apply) |
• Eyeglasses (frames and lenses) In-network: $0 copay
(limits apply) |
• Eyeglasses (frames and lenses) Out-of-network: $0 copay
(limits apply) |
• Eyeglass frames: Not covered
|
• Eyeglass lenses: Not covered
|
• Upgrades: Not covered
|
Medically-approved non-opioid pain management services |
• Chiropractic services: Not covered |
• Acupuncture: Not covered |
• Therapeutic Massage: Not covered |
• Alternative Therapies: Not covered |
More benefits |
• Transportation services: Some coverage |
• Transportation services for non-emergency care: Plan-approved locations: Not covered |
• Over-the-counter drug benefits: Some coverage |
• Meals for short duration: Some coverage |
• Annual physical exams: Some coverage |
• Telehealth: 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: Some coverage |
• Adult Day Health Services: Not covered |
• Nutritional/Dietary Benefit: Not covered |
• Home-Based Palliative Care: Some coverage |
• Support for Caregivers of Enrollees: Not covered |
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Some coverage |
• 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 |
Wellness programs (e.g., fitness, nursing hotline) |
• Covered
|
Transportation |
• In-network: $0 copay
(limits apply, authorization required) |
• Out-of-network: $0 copay
(limits apply, authorization required) |
Foot care (podiatry services) |
• Foot exams and treatment In-network: $30 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: 20% coinsurance
(authorization required) |
• Other Part B drugs In-network: 20% coinsurance
(authorization required) |
• Other Part B drugs Out-of-network: 20% coinsurance
(authorization required) |