** Base Plan ** |
Premium |
• Total monthly premium: $130.00 |
• Health plan premium: $130 |
• 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: No
|
Doctor visits |
• Primary: $0 copay
|
• Specialist: $0 copay
|
Diagnostic procedures/lab services/imaging |
• Diagnostic tests and procedures: $0 copay
|
• Lab services: $0 copay
|
• Diagnostic radiology services (e.g., MRI): $0-50 copay
|
• Outpatient x-rays: $0 copay
|
Emergency care/Urgent care |
• Emergency: $0 copay
|
• Urgent care: $0 copay
|
Inpatient hospital coverage |
• $100 per stay
|
Outpatient hospital coverage |
• $50 copay per visit
|
Skilled Nursing Facility |
• $0 per day for days 1 through 20 $25 per day for days 21 through 100
|
Preventive care |
• $0 copay
|
Ground ambulance |
• $0 copay
|
Rehabilitation services |
• Occupational therapy visit: $0 copay
|
• Physical therapy and speech and language therapy visit: $0 copay
|
Mental health services |
• Inpatient hospital - psychiatric: $100 per stay
|
• 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): $0 copay
|
• Prosthetics (e.g., braces, artificial limbs): $0 copay
|
• Diabetes supplies: $0 copay
|
Hearing |
• Hearing exam: $0 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: $0 copay
(limits apply) |
• Dental x-ray(s): $0 copay
(limits apply) |
Comprehensive dental |
• Non-routine services: $0 copay
(limits apply) |
• Diagnostic services: $0 copay
(limits apply) |
• Restorative services: $0 copay
(limits apply) |
• Endodontics: $0 copay
(limits apply) |
• Periodontics: $0 copay
(limits apply) |
• Extractions: $0 copay
(limits apply) |
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay
(limits apply) |
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: $0 copay
(limits apply) |
• Eyeglass lenses: $0 copay
(limits apply) |
• Upgrades: $0 copay
(limits apply) |
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 |
• WorldWide emergency coverage: Some coverage |
• Fitness Benefit: Some coverage |
• In-Home Support Services: Not covered |
• Bathroom Safety Devices: Not covered |
• Health Education: Some coverage |
• 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 |
Wellness programs (e.g., fitness, nursing hotline) |
• Covered
|
Transportation |
• Not covered
|
Foot care (podiatry services) |
• Foot exams and treatment: $0 copay
|
• Routine foot care: Not covered
|
Medicare Part B drugs |
• Chemotherapy: 20% coinsurance
|
• Other Part B drugs: 20% coinsurance
|