| ** Cost ** |
| Monthly premium, deductible, and limits on how much you pay for covered services |
| $79 per month. In addition you must keep paying your Medicare Part B premium. |
| This plan does not have a deductible. |
| 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: |
- $6 000 for services you receive from in-network providers.
|
- $6 000 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. |
| No. There are no limits on how much our plan will pay. |
| ** 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) | $4 copay | $8 copay | $12 copay | | Tier 2 (Generic) | $15 copay | $30 copay | $45 copay | | Tier 3 (Preferred Brand) | $47 copay | $94 copay | $141 copay | | Tier 4 (Non-Preferred Brand) | $100 copay | $200 copay | $300 copay | | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost | |
Preferred Retail Cost-Sharing | Tier | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | $0 | $0 | $0 | | Tier 2 (Generic) | $8 copay | $16 copay | $24 copay | | Tier 3 (Preferred Brand) | $40 copay | $80 copay | $120 copay | | Tier 4 (Non-Preferred Brand) | $95 copay | $190 copay | $285 copay | | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost | |
Standard Mail Order Cost-Sharing | Tier | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | $4 copay | $8 copay | $10 copay | | Tier 2 (Generic) | $15 copay | $30 copay | $37.50 copay | | Tier 3 (Preferred Brand) | $47 copay | $94 copay | $117.50 copay | | Tier 4 (Non-Preferred Brand) | $100 copay | $200 copay | $250 copay | | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost | |
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 but may pay more than you pay at an in-network pharmacy.
|
| 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. |
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 |
| $79 per month. In addition you must keep paying your Medicare Part B premium. |
| This plan does not have a deductible. |
| 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: |
- $6 000 for services you receive from in-network providers.
|
- $6 000 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. |
| No. There are no limits on how much our plan will pay. |
| ** Outpatient Care and Services ** |
| Acupuncture |
| Not covered |
| Ambulance |
|
- Out-of-network: $200 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: 30% 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: 30% of the cost
|
| Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- 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):- In-network: 20% of the cost
|
- Out-of-network: 30% of the cost
|
Diagnostic tests and procedures:- In-network: 0-15% of the cost depending on the service
|
- Out-of-network: 0-15% of the cost depending on the service
|
Lab services:- In-network: 0-20% of the cost depending on the service
|
- Out-of-network: 0-20% of the cost depending on the service
|
| Outpatient x-rays: |
- Out-of-network: $15 copay
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: 20% of the cost
|
- Out-of-network: 30% of the cost
|
| Doctor's office visits |
Primary care physician visit:- In-network: $0-20 copay depending on the service
|
- Out-of-network: $25 copay
|
| Specialist visit: |
- Out-of-network: 30% of the cost
|
| Durable medical equipment (wheelchairs, oxygen, etc.) |
- In-network: 20% of the cost
|
- Out-of-network: 30% of the cost
|
| Emergency care |
| $65 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: 30% of the cost
|
| Hearing services |
| Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: 30% of the cost
|
| 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. |
| The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. |
| 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: |
| $220 copay per day for days 1 through 7 |
| You pay nothing per day for days 8 through 90 |
|
|
| Out-of-network: |
| 30% of the cost per day for days 1 through 90 |
|
| Outpatient group therapy visit: |
- Out-of-network: 30% of the cost
|
| Outpatient individual therapy visit: |
- Out-of-network: 30% 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):- In-network: You pay nothing
|
- Out-of-network: 30% of the cost
|
| Occupational therapy visit: |
- Out-of-network: 30% of the cost
|
| Physical therapy and speech and language therapy visit: |
- Out-of-network: 30% of the cost
|
| Outpatient substance abuse |
| Group therapy visit: |
- Out-of-network: 30% of the cost
|
| Individual therapy visit: |
- Out-of-network: 30% of the cost
|
| Outpatient surgery |
| Ambulatory surgical center: |
- Out-of-network: 30% of the cost
|
Outpatient hospital:- In-network: $0-300 copay depending on the service
|
- Out-of-network: 30% 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: 30% of the cost
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 30% of the cost
|
| Renal dialysis |
- In-network: 20% of the cost
|
- Out-of-network: 20% of the cost
|
| Transportation |
| Not covered |
| Urgently needed services |
| $40 copay |
| If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services. See the "Inpatient Hospital Care" section for other costs. |
| Vision services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):- In-network: $0-35 copay depending on the service
|
- Out-of-network: 30% of the cost
|
Routine eye exam (for up to 1 every year):- In-network: You pay nothing
|
- Out-of-network: 30% of the cost
|
Eyeglasses or contact lenses after cataract surgery:- In-network: 20% of the cost
|
- Out-of-network: 30% of the cost
|
| ** 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: 30% of the cost
|
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 |
| The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. |
| Our plan covers an unlimited number of days for an inpatient hospital stay. |
|
| In-network: |
| $250 copay per day for days 1 through 7 |
| You pay nothing per day for days 8 through 90 |
| You pay nothing per day for days 91 and beyond |
|
|
| Out-of-network: |
| 30% 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 |
| $160 copay per day for days 21 through 100 |
|
|
| Out-of-network: |
| 30% 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) | $4 copay | $8 copay | $12 copay | | Tier 2 (Generic) | $15 copay | $30 copay | $45 copay | | Tier 3 (Preferred Brand) | $47 copay | $94 copay | $141 copay | | Tier 4 (Non-Preferred Brand) | $100 copay | $200 copay | $300 copay | | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost | |
Preferred Retail Cost-Sharing | Tier | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | $0 | $0 | $0 | | Tier 2 (Generic) | $8 copay | $16 copay | $24 copay | | Tier 3 (Preferred Brand) | $40 copay | $80 copay | $120 copay | | Tier 4 (Non-Preferred Brand) | $95 copay | $190 copay | $285 copay | | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost | |
Standard Mail Order Cost-Sharing | Tier | One-month supply | Two-month supply | Three-month supply |
|---|
| Tier 1 (Preferred Generic) | $4 copay | $8 copay | $10 copay | | Tier 2 (Generic) | $15 copay | $30 copay | $37.50 copay | | Tier 3 (Preferred Brand) | $47 copay | $94 copay | $117.50 copay | | Tier 4 (Non-Preferred Brand) | $100 copay | $200 copay | $250 copay | | Tier 5 (Specialty Tier) | 33% of the cost | 33% of the cost | 33% of the cost | |
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 but may pay more than you pay at an in-network pharmacy.
|
| 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. |
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: You pay nothing
|
- Out-of-network: 20% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- 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: 30% of the cost
|
| Hearing services |
| Exam to diagnose and treat hearing and balance issues: |
- Out-of-network: 30% of the cost
|
| ** Outpatient Medical Services and Supplies ** |
| Outpatient substance abuse |
| Group therapy visit: |
- Out-of-network: 30% of the cost
|
| Individual therapy visit: |
- Out-of-network: 30% of the cost
|
| Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 20% of the cost
|
- Out-of-network: 30% of the cost
|
Related medical supplies:- In-network: 20% of the cost
|
- Out-of-network: 30% of the cost
|
| ** Additional Benefits ** |
| Inpatient mental health care |
| For inpatient mental health care see the "Mental Health Care" section. |
or
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