** 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: $8,000 annual deductible
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• Other health plan deductibles: In-network: No
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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) |
• Not Applicable
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Optional supplemental benefits |
• No
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Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? |
• In-network: No
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Doctor visits |
• Primary: $0 copay after you pay your deductible
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• Specialist: $0 copay after you pay your deductible
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Diagnostic procedures/lab services/imaging |
• Diagnostic tests and procedures: $0 copay after you pay your deductible
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• Lab services: $0 copay after you pay your deductible
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• Diagnostic radiology services (e.g., MRI): $0 copay after you pay your deductible
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• Outpatient x-rays: $0 copay after you pay your deductible
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Emergency care/Urgent care |
• Emergency: $0 copay after you pay your deductible
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• Urgent care: $0 copay after you pay your deductible
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Inpatient hospital coverage |
• $0 copay after you pay your deductible
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Outpatient hospital coverage |
• $0 copay after you pay your deductible
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Skilled Nursing Facility |
• $0 copay after you pay your deductible
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Preventive care |
• $0 copay
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Ground ambulance |
• $0 copay after you pay your deductible
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Rehabilitation services |
• Occupational therapy visit: $0 copay after you pay your deductible
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• Physical therapy and speech and language therapy visit: $0 copay after you pay your deductible
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Mental health services |
• Inpatient hospital - psychiatric: $0 copay after you pay your deductible
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• Outpatient group therapy visit with a psychiatrist: $0 copay after you pay your deductible
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• Outpatient individual therapy visit with a psychiatrist: $0 copay after you pay your deductible
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• Outpatient group therapy visit: $0 copay after you pay your deductible
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• Outpatient individual therapy visit: $0 copay after you pay your deductible
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Medical equipment/supplies |
• Durable medical equipment (e.g., wheelchairs, oxygen): $0 copay after you pay your deductible
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• Prosthetics (e.g., braces, artificial limbs): $0 copay after you pay your deductible
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• Diabetes supplies: $0 copay after you pay your deductible
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Hearing |
• Hearing exam: $0 copay after you pay your deductible
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• Fitting/evaluation: Not covered
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• Hearing aids - inner ear: Not covered
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• Hearing aids - outer ear: Not covered
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• Hearing aids - over the ear: Not covered
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Preventive dental |
• Oral exam: Not covered
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• Cleaning: Not covered
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• Fluoride treatment: Not covered
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• Dental x-ray(s): Not covered
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Comprehensive dental |
• Non-routine services: Not covered
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• Diagnostic services: Not covered
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• Restorative services: Not covered
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• Endodontics: Not covered
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• Periodontics: Not covered
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• Extractions: Not covered
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• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
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Vision |
• Routine eye exam: Not covered
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• Other: Not covered
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• Contact lenses: Not covered
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• Eyeglasses (frames and lenses): Not covered
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• Eyeglass frames: Not covered
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• Eyeglass lenses: Not covered
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• Upgrades: Not covered
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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: Not covered |
• Meals for short duration: Not covered |
• Annual physical exams: Not covered |
• WorldWide emergency: Not covered |
• Fitness Benefit: Not covered |
• 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): Not covered |
• Counseling Services: Not covered |
Wellness programs (e.g., fitness, nursing hotline) |
• Not covered
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Transportation |
• Not covered
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Foot care (podiatry services) |
• Foot exams and treatment: $0 copay after you pay your deductible
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• Routine foot care: Not covered
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Medicare Part B drugs |
• Chemotherapy: $0 copay after you pay your deductible
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• Other Part B drugs: $0 copay after you pay your deductible
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