$132 monthly plan premium in addition to your monthly Medicare Part B premium.
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
This plan does not allow providers to balance bill (charging more than your cost share amount).
$6 700 out-of-pocket limit for Medicare-covered services.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
You may go to any doctor specialist or hospital that accepts the plan’s terms and conditions of payment.
** Extra Benefits **
Over-the-Counter Items
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.
Transportation
This plan does not cover supplemental routine transportation.
** Important Information **
Premium and Other Important Information
$132 monthly plan premium in addition to your monthly Medicare Part B premium.
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
This plan does not allow providers to balance bill (charging more than your cost share amount).
$6 700 out-of-pocket limit for Medicare-covered services.
Doctor and Hospital Choice
You may go to any doctor specialist or hospital that accepts the plan’s terms and conditions of payment.
** Inpatient Care **
Inpatient Hospital Care
You may go to any doctor or hospital that accepts the plan’s terms and conditions of payment. In emergencies you may go to any doctor or hospital even those that do not participate with the plan.
No limit to the number of days covered by the plan each hospital stay.
For Medicare-covered hospital stays:
Days 1 - 7: $225 copay per day
Days 8 - 60: $0 copay per day
Days 61 - 90: $100 copay per day
$0 copay for each additional hospital day.
For hospital stays:
Days 1 - 7: $225 copay per day
Days 8 - 60: $0 copay per day
Days 61 - 90: $100 copay per day
Inpatient Mental Health Care
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
For Medicare-covered hospital stays:
Days 1 - 7: $205 copay per day
Days 8 - 90: $0 copay per day
For hospital stays:
Days 1 - 7: $205 copay per day
Days 8 - 90: $0 copay per day
Skilled Nursing Facility (SNF)
Plan covers up to 100 days each benefit period
No prior hospital stay is required.
For SNF stays:
Days 1 - 20: $50 copay per day
Days 21 - 100: $150 copay per day
For each SNF stay:
Days 1 - 20: $50 copay per SNF day
Days 21 - 100: $150 copay per SNF day
Home Health Care
$0 copay for Medicare-covered home health visits
$0 copay for Medicare-covered home health visits
Hospice
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice.
** Outpatient Care **
Doctor Office Visits
You may go to any doctor that accepts the plan’s terms and conditions of payment.
$15 copay for each Medicare-covered primary care doctor visit.
$35 copay for each Medicare-covered specialist visit.
$15 copay for each Medicare-covered primary care doctor visit
$35 copay for each Medicare-covered specialist visit
Chiropractic Services
$15 copay for each Medicare-covered chiropractic visit
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor.
$15 copay for Medicare-covered chiropractic visits.
Podiatry Services
$35 copay for each Medicare-covered podiatry visit
Medicare-covered podiatry visits are for medically-necessary foot care.
$35 copay for Medicare-covered podiatry visits
Outpatient Mental Health Care
$35 copay for each Medicare-covered individual therapy visit
$35 copay for each Medicare-covered group therapy visit
$35 copay for each Medicare-covered individual therapy visit with a psychiatrist
$35 copay for each Medicare-covered group therapy visit with a psychiatrist
20% of the cost for Medicare-covered partial hospitalization program services
$35 copay for Medicare-covered Mental Health visits with a psychiatrist
$35 copay for Medicare-covered Mental Health visits
20% of the cost for Medicare-covered partial hospitalization program services
Outpatient Substance Abuse Care
25% of the cost for Medicare-covered individual substance abuse outpatient treatment visits
25% of the cost for Medicare-covered group substance abuse outpatient treatment visits
25% of the cost Medicare-covered substance abuse outpatient treatment visits
Outpatient Services
20% of the cost for each Medicare-covered ambulatory surgical center visit
20% to 25% of the cost for each Medicare-covered outpatient hospital facility visit
20% to 25% of the cost for Medicare-covered outpatient hospital facility visits
20% of the cost for Medicare-covered ambulatory surgical center visits
Ambulance Services
20% of the cost for Medicare-covered ambulance benefits.
20% of the cost for Medicare-covered ambulance benefits.
Emergency Care
$65 copay for Medicare-covered emergency room visits
$25 000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year.
Urgently Needed Care
$15 to $35 copay for Medicare-covered urgently-needed-care visits
Outpatient Rehabilitation Services
There may be limits on physical therapy occupational therapy and speech and language pathology visits. If so there may be exceptions to these limits.
$35 copay [or 25% of the cost] for Medicare-covered Occupational Therapy visits
$35 copay [or 25% of the cost] for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits
$35 copay [or 20% to 25% of the cost] for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits
$35 copay [or 20% to 25% of the cost] for Medicare-covered Occupational Therapy visits.
** Outpatient Medical Services and Supplies **
Durable Medical Equipment
20% of the cost for Medicare-covered durable medical equipment
You may pay less if you purchase these items from the plan’s preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors.
20% of the cost for Medicare-covered durable medical equipment
Prosthetic Devices
20% of the cost for Medicare-covered prosthetic devices
20% of the cost for Medicare-covered prosthetic devices.
Diabetes Programs and Supplies
$0 copay for Medicare-covered Diabetes self-management training
0% to 20% of the cost for Medicare-covered Diabetes monitoring supplies
0% of the cost for Medicare-covered Therapeutic shoes or inserts
$0 copay for Medicare-covered Diabetes self-management training
20% of the cost for Medicare-covered Diabetes monitoring supplies
20% of the cost for Medicare-covered Therapeutic shoes or inserts
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
$0 to $35 copay [or 25% of the cost] for Medicare-covered lab services
$0 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic procedures and tests
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered X-rays
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays)
$35 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services
$35 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered outpatient X-rays
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic radiology services
$0 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic procedures tests and lab services
** Preventive Services **
Cardiac and Pulmonary Rehabilitation Services
$35 copay [or 25% of the cost] for Medicare-covered Cardiac Rehabilitation Services
$35 copay [or 25% of the cost] for Medicare-covered Intensive Cardiac Rehabilitation Services
$35 copay [or 25% of the cost] for Medicare-covered Pulmonary Rehabilitation Services
$35 copay [or 25% of the cost] for Medicare-covered Cardiac Rehabilitation Services
$35 copay [or 25% of the cost] for Medicare-covered Intensive Cardiac Rehabilitation Services
$35 copay [or 25% of the cost] for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services and Wellness/Education Programs
$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.
$0 copay for an annual physical exam
The plan covers the following supplemental education/wellness programs:
Health Education
Additional Smoking and Tobacco Use Cessation Visits
Health Club Membership/Fitness Classes
Nursing Hotline
$0 copay for Medicare-covered preventive services
$0 copay for an annual physical exam
50% of the cost for supplemental education/wellness programs
Kidney Disease and Conditions
20% of the cost for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
$0 copay for Medicare-covered kidney disease education services
20% of the cost for Medicare-covered renal dialysis
Outpatient Prescription Drugs
20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.
20% of the cost for Medicare Part B drugs out-of-network.
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.humana.com/members/tools/prescription_tools/medicare_drug_list.asp on the web.
Different out-of-pocket costs may apply for people who
have limited incomes
live in long term care facilities or
have access to Indian/Tribal/Urban (Indian Health Service) providers.
The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel).
Total yearly drug costs are the total drug costs paid by both you and a Part D plan.
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
Some drugs have quantity limits.
Your provider must get prior authorization from Humana Gold Choice H8145-008 (PFFS) for certain drugs.
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.
The plan charges a minimum cost sharing amount for certain low-cost drugs.
If you request a formulary exception for a drug and Humana Gold Choice H8145-008 (PFFS) approves the exception you will pay Tier 3: Non-Preferred Brand cost sharing for that drug.
$0 deductible.
You pay the following until total yearly drug costs reach $2 970:
Tier 1: Preferred Generic
Tier 2: Preferred Brand
Tier 3: Non-Preferred Brand
Tier 4: Specialty Tier
$7 copay for a one-month (30-day) supply of drugs in this tier
$40 copay for a one-month (30-day) supply of drugs in this tier
$80 copay for a one-month (30-day) supply of drugs in this tier
33% coinsurance for a one-month (30-day) supply of drugs in this tier
$21 copay for a three-month (90-day) supply of drugs in this tier
$120 copay for a three-month (90-day) supply of drugs in this tier
$240 copay for a three-month (90-day) supply of drugs in this tier
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
Tier 1: Preferred Generic
Tier 2: Preferred Brand
Tier 3: Non-Preferred Brand
Tier 4: Specialty Tier
$7 copay for a one-month (31-day) supply of drugs in this tier
$40 copay for a one-month (31-day) supply of drugs in this tier
$80 copay for a one-month (31-day) supply of drugs in this tier
33% coinsurance for a one-month (31-day) supply of drugs in this tier
Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed.
Tier 1: Preferred Generic
Tier 2: Preferred Brand
Tier 3: Non-Preferred Brand
Tier 4: Specialty Tier
$0 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
$40 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
$80 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
$0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
$110 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
$230 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
$7 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
$40 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
$80 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
$21 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
$120 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
$240 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
After your total yearly drug costs reach $2 970 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan’s costs for brand drugs and 79% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4 750.
The plan covers few formulary generics (less than 10% of formulary generic drugs) few formulary brands (less than 10% of formulary brand drugs) through the coverage gap.
The plan offers additional coverage in the gap for the following tiers. You pay the following:
Tier 1: Preferred Generic
Tier 2: Preferred Brand
Tier 3: Non-Preferred Brand
Tier 4: Specialty Tier
$7 copay for a one-month (30-day) supply of select drugs covered in this tier
$40 copay for a one-month (30-day) supply of select drugs covered in this tier
$80 copay for a one-month (30-day) supply of select drugs covered in this tier
33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier
$21 copay for a three-month (90-day) supply of select drugs covered in this tier
$120 copay for a three-month (90-day) supply of select drugs covered in this tier
$240 copay for a three-month (90-day) supply of select drugs covered in this tier
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
Tier 1: Preferred Generic
Tier 2: Preferred Brand
Tier 3: Non-Preferred Brand
Tier 4: Specialty Tier
$7 copay for a one-month (31-day) supply of select drugs covered in this tier
$40 copay for a one-month (31-day) supply of select drugs covered in this tier
$80 copay for a one-month (31-day) supply of select drugs covered in this tier
33% coinsurance for a one-month (31-day) supply of select drugs covered in this tier
Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed.
Tier 1: Preferred Generic
Tier 2: Preferred Brand
Tier 3: Non-Preferred Brand
Tier 4: Specialty Tier
$0 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
$40 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
$80 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
$0 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
$110 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
$230 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
$7 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
$40 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
$80 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
$21 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
$120 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
$240 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
Please contact the plan for a complete list of drugs covered through the gap.
After your yearly out-of-pocket drug costs reach $4 750 you pay the greater of:
5% coinsurance or
$2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs.
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from Humana Gold Choice H8145-008 (PFFS).
You will be reimbursed up to the plan’s cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 970:
Tier 1: Preferred Generic
Tier 2: Preferred Brand
Tier 3: Non-Preferred Brand
Tier 4: Specialty Tier
$7 copay for a one-month (30-day) supply of drugs in this tier
$40 copay for a one-month (30-day) supply of drugs in this tier
$80 copay for a one-month (30-day) supply of drugs in this tier
33% coinsurance for a one-month (30-day) supply of drugs in this tier
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.
You will be reimbursed up to 21% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).
The plan covers few formulary generics (less than 10% of formulary generic drugs) few formulary brands (less than 10% of formulary brand drugs) through the coverage gap.
You will be reimbursed for these drugs purchased out-of-network up to the plan’s cost of the drug minus the following:
Tier 1: Preferred Generic
Tier 2: Preferred Brand
Tier 3: Non-Preferred Brand
Tier 4: Specialty Tier
$7 copay for a one-month (30-day) supply of select drugs covered in this tier
$40 copay for a one-month (30-day) supply of select drugs covered in this tier
$80 copay for a one-month (30-day) supply of select drugs covered in this tier
33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.
After your yearly out-of-pocket drug costs reach $4 750 you will be reimbursed for drugs purchased out-of-network up to the plan’s cost of the drug minus your cost share which is the greater of:
5% coinsurance or
$2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs.
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.
Dental Services
This plan covers some preventive dental benefits for an extra cost (see "Optional Supplemental Benefits.")
$35 copay for Medicare-covered dental benefits
$35 copay for Medicare-covered comprehensive dental benefits
Hearing Services
In general supplemental routine hearing exams and hearing aids not covered.
$35 copay for Medicare-covered diagnostic hearing exams
$35 copay for Medicare-covered diagnostic hearing exams.
** Additional Benefits **
Vision Services
$25 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.
$0 to $35 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.
$0 copay for up to 1 supplemental routine eye exam(s) every year
$0 to $35 copay for Medicare-covered eye exams
$0 copay for supplemental eye exams
$25 copay for Medicare-covered eye wear
$130 plan coverage limit for supplemental routine eye exams every year. This limit applies to both in-network and out-of-network benefits.
Over-the-Counter Items
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.
Transportation
This plan does not cover supplemental routine transportation.
Acupuncture
This plan does not cover Acupuncture.
** Inpatient Care **
Inpatient Hospital Care
You may go to any doctor or hospital that accepts the plan’s terms and conditions of payment. In emergencies you may go to any doctor or hospital even those that do not participate with the plan.
No limit to the number of days covered by the plan each hospital stay.
For Medicare-covered hospital stays:
Days 1 - 7: $225 copay per day
Days 8 - 60: $0 copay per day
Days 61 - 90: $100 copay per day
$0 copay for each additional hospital day.
For hospital stays:
Days 1 - 7: $225 copay per day
Days 8 - 60: $0 copay per day
Days 61 - 90: $100 copay per day
** Outpatient Care **
Doctor Office Visits
You may go to any doctor that accepts the plan’s terms and conditions of payment.
$15 copay for each Medicare-covered primary care doctor visit.
$35 copay for each Medicare-covered specialist visit.
$15 copay for each Medicare-covered primary care doctor visit
$35 copay for each Medicare-covered specialist visit
Outpatient Services
20% of the cost for each Medicare-covered ambulatory surgical center visit
20% to 25% of the cost for each Medicare-covered outpatient hospital facility visit
20% to 25% of the cost for Medicare-covered outpatient hospital facility visits
20% of the cost for Medicare-covered ambulatory surgical center visits
Ambulance Services
20% of the cost for Medicare-covered ambulance benefits.
20% of the cost for Medicare-covered ambulance benefits.
** Outpatient Medical Services and Supplies **
Durable Medical Equipment
20% of the cost for Medicare-covered durable medical equipment
You may pay less if you purchase these items from the plan’s preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors.
20% of the cost for Medicare-covered durable medical equipment
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
$0 to $35 copay [or 25% of the cost] for Medicare-covered lab services
$0 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic procedures and tests
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered X-rays
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays)
$35 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services
$35 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered outpatient X-rays
$15 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic radiology services
$0 to $35 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic procedures tests and lab services
** Additional Benefits **
Over-the-Counter Items
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.
Transportation
This plan does not cover supplemental routine transportation.
** Cost **
Premium and Other Important Information
Package: 1 - MyOption Dental - Low PPO:
$13 monthly premium in addition to your $132 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
Preventive Dental
Comprehensive Dental
$1 000 plan coverage limit every year for these benefits.
** Important Information **
Package: 1 - MyOption Dental - Low PPO:
$13 monthly premium in addition to your $132 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
Preventive Dental
Comprehensive Dental
$1 000 plan coverage limit every year for these benefits.
** Preventive Services **
Dental Services
Plan offers additional comprehensive dental benefits.
up to 2 oral exam(s) every year
up to 2 cleaning(s) every year
up to 1 dental x-ray(s) every year
30% of the cost for preventive dental services
55% of the cost for comprehensive dental services
$1 000 plan coverage limit for dental benefits every year. This limit applies to both in-network and out-of-network benefits.
** Cost **
Premium and Other Important Information
Package: 2 - MyOption Plus:
$22 monthly premium in addition to your $132 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
Preventive Dental
Comprehensive Dental
Eye Exams
Eye Wear
** Important Information **
Package: 2 - MyOption Plus:
$22 monthly premium in addition to your $132 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
Preventive Dental
Comprehensive Dental
Eye Exams
Eye Wear
** Preventive Services **
Dental Services
Plan offers additional comprehensive dental benefits.
up to 2 oral exam(s) every year
up to 2 cleaning(s) every year
up to 1 dental x-ray(s) every year
30% of the cost for preventive dental services
55% of the cost for comprehensive dental services
$1 000 plan coverage limit for dental benefits every year. This limit applies to both in-network and out-of-network benefits.
** Additional Benefits **
Vision Services
$0 copay for up to 1 pair(s) of contacts every year
$0 copay for up to 1 pair(s) of glasses every year
$0 copay for up to 1 supplemental routine eye exam(s) every year
** Cost **
Premium and Other Important Information
Package: 3 - MyOption Platinum Dental:
$29 monthly premium in addition to your $132 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
Preventive Dental
Comprehensive Dental
$2 000 plan coverage limit every year for these benefits.
** Important Information **
Package: 3 - MyOption Platinum Dental:
$29 monthly premium in addition to your $132 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
Preventive Dental
Comprehensive Dental
$2 000 plan coverage limit every year for these benefits.
** Preventive Services **
Dental Services
Plan offers additional comprehensive dental benefits.
up to 3 oral exam(s) every year
up to 2 cleaning(s) every year
up to 1 dental x-ray(s) every year
50% of the cost for preventive dental services
50% to 75% of the cost for comprehensive dental services
$2 000 plan coverage limit for dental benefits every year. This limit applies to both in-network and out-of-network benefits.
