| ** Cost ** |
| Monthly premium, deductible, and limits on how much you pay for covered services |
| $188 per month. In addition you must keep paying your Medicare Part B premium. |
| This plan has deductibles for some hospital and medical services. |
| $500 per year for out-of-network services. |
| This plan does not have a deductible for Part D prescription drugs. |
| Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. |
| Your yearly limit(s) in this plan: |
- $4 500 for services you receive from in-network providers.
|
- $7 500 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
|
| If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. |
| Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. |
| ** Doctor and Hospital Choice ** |
| Acupuncture |
| Not covered |
| ** Extra Benefits ** |
| Inpatient mental health care |
| For inpatient mental health care see the "Mental Health Care" section. |
| Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs1:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Other Part B drugs1:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
You pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
|
| You may get your drugs at network retail pharmacies and mail order pharmacies. |
Standard Retail Cost-Sharing | Tier | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | $6 copay | $12 copay | $15 copay | | Tier 2 (Generic) | $12 copay | $24 copay | $30 copay | | Tier 3 (Preferred Brand) | $47 copay | $94 copay | $117.50 copay | | Tier 4 (Non-Preferred Brand) | 50% of the cost | 50% of the cost | 50% of the cost | | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | |
Preferred Retail Cost-Sharing | Tier | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | $0 | $0 | $0 | | Tier 2 (Generic) | $7 copay | $14 copay | $17.50 copay | | Tier 3 (Preferred Brand) | $47 copay | $94 copay | $117.50 copay | | Tier 4 (Non-Preferred Brand) | 50% of the cost | 50% of the cost | 50% of the cost | | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | |
Standard Mail Order Cost-Sharing | Tier | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | $6 copay | $12 copay | $15 copay | | Tier 2 (Generic) | $12 copay | $24 copay | $30 copay | | Tier 3 (Preferred Brand) | $47 copay | $94 copay | $117.50 copay | | Tier 4 (Non-Preferred Brand) | 50% of the cost | 50% of the cost | 50% of the cost | | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | |
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
|
You may get drugs from an out-of-network pharmacy and pay the same as an in-network pharmacy but you will get less of the drug.
|
| Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap. |
Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
|
Standard Retail Cost-Sharing | Tier | Drugs Covered | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | All | $6 copay | $12 copay | $15 copay | |
Preferred Retail Cost-Sharing | Tier | Drugs Covered | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | All | $0 | $0 | $0 | |
Standard Mail Order Cost-Sharing | Tier | Drugs Covered | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | All | $6 copay | $12 copay | $15 copay | |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
- $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
|
| ** Important Information ** |
| Monthly premium, deductible, and limits on how much you pay for covered services |
| $188 per month. In addition you must keep paying your Medicare Part B premium. |
| This plan has deductibles for some hospital and medical services. |
| $500 per year for out-of-network services. |
| This plan does not have a deductible for Part D prescription drugs. |
| Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. |
| Your yearly limit(s) in this plan: |
- $4 500 for services you receive from in-network providers.
|
- $7 500 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
|
| If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. |
| Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. |
| ** Outpatient Care and Services ** |
| Acupuncture |
| Not covered |
| Ambulance |
|
- Out-of-network: $100 copay
|
| Chiropractic care |
| Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): |
- Out-of-network: 20% of the cost
|
| Dental services |
| Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): |
- Out-of-network: 20% of the cost
|
| Preventive dental services: |
Cleaning:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Dental x-ray(s):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Fluoride treatment:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Oral exam:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
| Our plan pays up to $150 every year for preventive dental services from any provider. |
| Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: 0-20% of the cost depending on the supply
|
- Out-of-network: 20% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Therapeutic shoes or inserts:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
| Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting) |
| Diagnostic radiology services (such as MRIs CT scans): |
- Out-of-network: 20% of the cost
|
| Diagnostic tests and procedures: |
- Out-of-network: 20% of the cost
|
Lab services:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
| Outpatient x-rays: |
- Out-of-network: 20% of the cost
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
| Doctor's office visits |
Primary care physician visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
| Specialist visit: |
- Out-of-network: 20% of the cost
|
| Durable medical equipment (wheelchairs, oxygen, etc.) |
- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
| Emergency care |
| $75 copay |
| If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs. |
| Foot care (podiatry services) |
| Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: |
- Out-of-network: 20% of the cost
|
| Hearing services |
| Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: 20% of the cost
|
| Hearing aid fitting/evaluation (for up to 1 every year): |
- Out-of-network: 20% of the cost
|
Hearing aid:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
| Our plan pays up to $500 every year for hearing aids from any provider. |
| Home health care |
- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
| Mental health care |
| Inpatient visit: |
| Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. |
| Our plan covers 90 days for an inpatient hospital stay. |
| Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days. |
|
| In-network: |
| $200 copay per day for days 1 through 5 |
| You pay nothing per day for days 6 through 90 |
|
|
| Out-of-network: |
| 20% of the cost per day for days 1 through 90 |
|
| Outpatient group therapy visit: |
- Out-of-network: 20% of the cost
|
| Outpatient individual therapy visit: |
- Out-of-network: 20% of the cost
|
| Outpatient rehabilitation |
| Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): |
- Out-of-network: 20% of the cost
|
| Occupational therapy visit: |
- Out-of-network: 20% of the cost
|
| Physical therapy and speech and language therapy visit: |
- Out-of-network: 20% of the cost
|
| Outpatient substance abuse |
| Group therapy visit: |
- Out-of-network: 20% of the cost
|
| Individual therapy visit: |
- Out-of-network: 20% of the cost
|
| Outpatient surgery |
| Ambulatory surgical center: |
- Out-of-network: 20% of the cost
|
| Outpatient hospital: |
- Out-of-network: 20% of the cost
|
| Over-the-counter items |
| Not Covered |
| Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
| Renal dialysis |
- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
| Transportation |
| Not covered |
| Urgently needed services |
| $50 copay |
| Vision services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):- In-network: $0-15 copay depending on the service
|
- Out-of-network: 20% of the cost
|
Routine eye exam (for up to 1 every year):- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Contact lenses:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglasses (frames and lenses):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglasses or contact lenses after cataract surgery:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
| Our plan pays up to $150 every year for contact lenses and eyeglasses (frames and lenses) from any provider. |
| ** Hospice ** |
| Hospice |
| You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. |
| ** Preventive Care ** |
| Preventive care |
- In-network: You pay nothing
|
- Out-of-network: 0-20% of the cost depending on the service
|
Our plan covers many preventive services including: - Abdominal aortic aneurysm screening
- Alcohol misuse counseling
- Bone mass measurement
- Breast cancer screening (mammogram)
- Cardiovascular disease (behavioral therapy)
- Cardiovascular screenings
- Cervical and vaginal cancer screening
- Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
- Depression screening
- Diabetes screenings
- HIV screening
- Medical nutrition therapy services
- Obesity screening and counseling
- Prostate cancer screenings (PSA)
- Sexually transmitted infections screening and counseling
- Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
- Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
- "Welcome to Medicare" preventive visit (one-time)
- Yearly "Wellness" visit
Any additional preventive services approved by Medicare during the contract year will be covered. |
| ** Inpatient Care ** |
| Inpatient hospital care |
| Our plan covers an unlimited number of days for an inpatient hospital stay. |
|
| In-network: |
| $200 copay per day for days 1 through 4 |
| You pay nothing per day for days 5 through 90 |
| You pay nothing per day for days 91 and beyond |
|
|
| Out-of-network: |
| 20% of the cost per day for days 1 and beyond |
|
| Inpatient mental health care |
| For inpatient mental health care see the "Mental Health Care" section. |
| Skilled Nursing Facility (SNF) |
| Our plan covers up to 100 days in a SNF. |
|
| In-network: |
| You pay nothing per day for days 1 through 20 |
| $100 copay per day for days 21 through 100 |
|
|
| Out-of-network: |
| 20% of the cost per day for days 1 through 100 |
|
| Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs1:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Other Part B drugs1:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
You pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
|
| You may get your drugs at network retail pharmacies and mail order pharmacies. |
Standard Retail Cost-Sharing | Tier | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | $6 copay | $12 copay | $15 copay | | Tier 2 (Generic) | $12 copay | $24 copay | $30 copay | | Tier 3 (Preferred Brand) | $47 copay | $94 copay | $117.50 copay | | Tier 4 (Non-Preferred Brand) | 50% of the cost | 50% of the cost | 50% of the cost | | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | |
Preferred Retail Cost-Sharing | Tier | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | $0 | $0 | $0 | | Tier 2 (Generic) | $7 copay | $14 copay | $17.50 copay | | Tier 3 (Preferred Brand) | $47 copay | $94 copay | $117.50 copay | | Tier 4 (Non-Preferred Brand) | 50% of the cost | 50% of the cost | 50% of the cost | | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | |
Standard Mail Order Cost-Sharing | Tier | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | $6 copay | $12 copay | $15 copay | | Tier 2 (Generic) | $12 copay | $24 copay | $30 copay | | Tier 3 (Preferred Brand) | $47 copay | $94 copay | $117.50 copay | | Tier 4 (Non-Preferred Brand) | 50% of the cost | 50% of the cost | 50% of the cost | | Tier 5 (Specialty Tier) | 33% of the cost | Not Offered | Not Offered | |
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
|
You may get drugs from an out-of-network pharmacy and pay the same as an in-network pharmacy but you will get less of the drug.
|
| Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap. |
Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
|
Standard Retail Cost-Sharing | Tier | Drugs Covered | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | All | $6 copay | $12 copay | $15 copay | |
Preferred Retail Cost-Sharing | Tier | Drugs Covered | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | All | $0 | $0 | $0 | |
Standard Mail Order Cost-Sharing | Tier | Drugs Covered | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | All | $6 copay | $12 copay | $15 copay | |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
- $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
|
| ** Outpatient Care ** |
| Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: 0-20% of the cost depending on the supply
|
- Out-of-network: 20% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Therapeutic shoes or inserts:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
| Foot care (podiatry services) |
| Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: |
- Out-of-network: 20% of the cost
|
| Hearing services |
| Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: 20% of the cost
|
| Hearing aid fitting/evaluation (for up to 1 every year): |
- Out-of-network: 20% of the cost
|
Hearing aid:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
| Our plan pays up to $500 every year for hearing aids from any provider. |
| ** Outpatient Medical Services and Supplies ** |
| Outpatient substance abuse |
| Group therapy visit: |
- Out-of-network: 20% of the cost
|
| Individual therapy visit: |
- Out-of-network: 20% of the cost
|
| Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
| ** Additional Benefits ** |
| Inpatient mental health care |
| For inpatient mental health care see the "Mental Health Care" section. |
or
email and view benefits chart
