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2014 Medicare Advantage Plan Benefit Details



2014 Medicare Advantage Plan Details
Plan Name:Humana Gold Choice H8145-087 (PFFS)
Location (County, State ZIP):Hinds, Mississippi
Plan ID:H8145 - 087     Click to see other plans

Click here for the Humana Gold Choice H8145-087 (PFFS) enrollment options and to have a copy of this chart sent to your email. Enroll in Humana Gold Choice H8145-087 (PFFS)

— Plan Features —
Monthly Premium:$82.00
Monthly Premium with Low-Income Subsidy:100%75%50%25%
$0.00$0.00$0.00$0.00
Annual Rx Deductible:$80
Health Plan Type:PFFS
Maximum Out-of-Pocket Limit
for Parts A & B (MOOP):
$0
Gap Coverage:No Gap Coverage
Total Number of Formulary Drugs:3852    Browse Plan Formulary
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Cost-Sharing during
       initial coverage phase:
$4.00$10.00$45.00$95.0031%
  — Number of Drugs per Tier:2349287961482412
Plan’s Summary Star Rating: Insufficient data to rate this plan.
   - Customer Service Rating: 4 out of 5 Stars.
   - Member Experience Rating: 4 out of 5 Stars.
   - Drug Cost Accuracy Rating: 4 out of 5 Stars.

— Plan Health Benefits —
** Cost **
Premium and Other Important Information
$82 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 **
Wellness/Education and Other Supplemental Benefits & Services
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
  • 50% of the cost for supplemental education/wellness programs
    Acupuncture
    This plan does not cover Acupuncture and other alternative therapies.
    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.
    ** Important Information **
    Premium and Other Important Information
    $82 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 - 5: $295 copay per day
  • Days 6 - 90: $0 copay per day
  • $0 copay for each additional non-Medicare-covered hospital day.
    For Medicare-covered hospital stays:
    • Days 1 - 5: $295 copay per day
  • Days 6 - 90: $0 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 - 5: $295 copay per day
  • Days 6 - 90: $0 copay per day
  • Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.
    For Medicare-covered hospital stays:
    • Days 1 - 5: $295 copay per day
  • Days 6 - 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 - 7: $0 copay per day
  • Days 8 - 20: $25 copay per day
  • Days 21 - 100: $100 copay per day
  • For each Medicare-covered SNF stay:
    • Days 1 - 7: $0 copay per SNF day
  • Days 8 - 20: $25 copay per SNF day
  • Days 21 - 100: $100 copay per SNF day
  • Home Health Care
    $0 copay for each Medicare-covered home health visit
    $0 copay for Medicare-covered home health visits
    Hospice
    You must get care from a Medicare-certified hospice. You must consult with your plan 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.
    $15 to $40 copay for each Medicare-covered specialist visit.
    $15 copay for each Medicare-covered primary care doctor visit
    $15 to $40 copay for each Medicare-covered specialist visit
    Chiropractic Services
    $20 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).
    $20 copay for Medicare-covered chiropractic visits.
    Podiatry Services
    $40 copay for each Medicare-covered podiatry visit
    Medicare-covered podiatry visits are for medically necessary foot care.
    $40 copay for Medicare-covered podiatry visits
    Outpatient Mental Health Care
    $40 copay for each Medicare-covered individual therapy visit
    $40 copay for each Medicare-covered group therapy visit
    $40 copay for each Medicare-covered individual therapy visit with a psychiatrist
    $40 copay for each Medicare-covered group therapy visit with a psychiatrist
    20% of the cost for Medicare-covered partial hospitalization program services
    $40 copay for Medicare-covered Mental Health visits with a psychiatrist
    $40 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 for Medicare-covered substance abuse outpatient treatment visits
    Outpatient Services
    20% of the cost for each Medicare-covered ambulatory surgical center visit
    $150 copay [or 20% to 25% of the cost] for each Medicare-covered outpatient hospital facility visit
    $150 copay [or 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 $40 copay for Medicare-covered urgently-needed-care visits
    Outpatient Rehabilitation Services
    Medically necessary physical therapy occupational therapy and speech and language pathology services are covered.
    $15 copay [or 25% of the cost] for Medicare-covered Occupational Therapy visits
    $15 copay [or 25% of the cost] for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits
    $15 copay [or 25% of the cost] for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits
    $15 copay [or 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 medical supplies related to prosthetics splints and other 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
    $10 copay 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 $40 copay [or 25% of the cost] for Medicare-covered lab services
    $0 to $40 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic procedures and tests
    $15 to $40 copay [or 20% to 25% of the cost] for Medicare-covered X-rays
    $150 copay for Medicare-covered diagnostic radiology services (not including X-rays)
    $40 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services
    If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $15 to $40 may apply
    $40 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services
    $15 to $40 copay [or 20% to 25% of the cost] for Medicare-covered outpatient X-rays
    $150 copay for Medicare-covered diagnostic radiology services
    $0 to $40 copay [or 25% of the cost] for Medicare-covered diagnostic procedures and tests
    $0 to $40 copay [or 25% of the cost] for Medicare-covered lab services
    If the doctor provides you services in addition to (Diagnostic Radiological Services ) separate cost sharing of $15 to $40 may apply
    ** Preventive Services **
    Cardiac and Pulmonary Rehabilitation Services
    $15 copay [or 25% of the cost] for Medicare-covered Cardiac Rehabilitation Services
    $15 copay [or 25% of the cost] for Medicare-covered Intensive Cardiac Rehabilitation Services
    $15 copay [or 25% of the cost] for Medicare-covered Pulmonary Rehabilitation Services
    $15 copay [or 25% of the cost] for Medicare-covered Cardiac Rehabilitation Services
    $15 copay [or 25% of the cost] for Medicare-covered Intensive Cardiac Rehabilitation Services
    $15 copay [or 25% of the cost] for Medicare-covered Pulmonary Rehabilitation Services
    Preventive Services
    $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 a supplemental annual physical exam
    $0 copay for Medicare-covered preventive services
    $0 copay for a supplemental annual physical exam
    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/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/ 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 H8145-087 (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 H8145-087 (PFFS) approves the exception you will pay Tier 4: Non-Preferred Brand cost sharing for that drug.
    $80 deductible on all drugs except Tier 1: Preferred Generic Tier 2: Non-Preferred Generic Tier 3: Preferred Brand drugs.
    After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 850:
    Tier 1: Preferred Generic
    Tier 2: Non-Preferred Generic
    Tier 3: Preferred Brand
    Tier 4: Non-Preferred Brand
    Tier 5: Specialty Tier
    Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
    You can get drugs the following way(s):
    • $4 copay for a one-month (30-day) supply of drugs in this tier
  • $10 copay for a one-month (30-day) supply of drugs in this tier
  • $45 copay for a one-month (30-day) supply of drugs in this tier
  • $95 copay for a one-month (30-day) supply of drugs in this tier
  • 31% coinsurance for a one-month (30-day) supply of drugs in this tier
  • $12 copay for a three-month (90-day) supply of drugs in this tier
  • $30 copay for a three-month (90-day) supply of drugs in this tier
  • $135 copay for a three-month (90-day) supply of drugs in this tier
  • $285 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.
    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: Non-Preferred Generic
    Tier 3: Preferred Brand
    Tier 4: Non-Preferred Brand
    Tier 5: Specialty Tier
    Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
    You can get drugs the following way(s):
    • $4 copay for a one-month (31-day) supply of drugs in this tier
  • $10 copay for a one-month (31-day) supply of drugs in this tier
  • $45 copay for a one-month (31-day) supply of drugs in this tier
  • $95 copay for a one-month (31-day) supply of drugs in this tier
  • 31% coinsurance for a one-month (31-day) supply of drugs in this tier
  • Tier 1: Preferred Generic
    Tier 2: Non-Preferred Generic
    Tier 3: Preferred Brand
    Tier 4: Non-Preferred Brand
    Tier 5: Specialty Tier
    Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
    You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s):
    • $4 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $10 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $45 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $95 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 31% 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.
  • $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $125 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $275 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $4 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $10 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $45 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $95 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 31% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $12 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $30 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $285 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.
    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 $2 850 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 72% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 550.
    After your yearly out-of-pocket drug costs reach $4 550 you pay the greater of:
    • 5% coinsurance or
    • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 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 H8145-087 (PFFS).
    You can get out-of-network drugs the following way:
    After you pay your yearly deductible you will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until your total yearly drug costs reach $2 850:
    Tier 1: Preferred Generic
    Tier 2: Non-Preferred Generic
    Tier 3: Preferred Brand
    Tier 4: Non-Preferred Brand
    Tier 5: Specialty Tier
    • $4 copay for a one-month (30-day) supply of drugs in this tier
  • $10 copay for a one-month (30-day) supply of drugs in this tier
  • $45 copay for a one-month (30-day) supply of drugs in this tier
  • $95 copay for a one-month (30-day) supply of drugs in this tier
  • 31% 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 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. 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 $4 550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).
    After your yearly out-of-pocket drug costs reach $4 550 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
    • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 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.")
    $40 copay for Medicare-covered dental benefits
    $40 copay for Medicare-covered comprehensive dental benefits
    Hearing Services
    In general supplemental routine hearing exams and hearing aids not covered.
    $40 copay for Medicare-covered diagnostic hearing exams
    $40 copay for Medicare-covered diagnostic hearing exams.
    ** Additional Benefits **
    Vision Services
    $0 to $40 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye including an annual glaucoma screening for people at risk
    $0 copay for up to 1 supplemental routine eye exam(s) every year
    $0 copay for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery.
    $0 to $40 copay for Medicare-covered eye exams
    $0 copay for supplemental routine eye exams
    $0 copay for Medicare-covered eyewear
    $40 plan coverage limit for supplemental eye exams every year. This limit applies to both in-network and out-of-network benefits.
    Wellness/Education and Other Supplemental Benefits & Services
    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
  • 50% of the cost for supplemental education/wellness programs
    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 and other alternative therapies.
    ** 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 - 5: $295 copay per day
  • Days 6 - 90: $0 copay per day
  • $0 copay for each additional non-Medicare-covered hospital day.
    For Medicare-covered hospital stays:
    • Days 1 - 5: $295 copay per day
  • Days 6 - 90: $0 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.
    $15 to $40 copay for each Medicare-covered specialist visit.
    $15 copay for each Medicare-covered primary care doctor visit
    $15 to $40 copay for each Medicare-covered specialist visit
    Outpatient Services
    20% of the cost for each Medicare-covered ambulatory surgical center visit
    $150 copay [or 20% to 25% of the cost] for each Medicare-covered outpatient hospital facility visit
    $150 copay [or 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 $40 copay [or 25% of the cost] for Medicare-covered lab services
    $0 to $40 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic procedures and tests
    $15 to $40 copay [or 20% to 25% of the cost] for Medicare-covered X-rays
    $150 copay for Medicare-covered diagnostic radiology services (not including X-rays)
    $40 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services
    If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $15 to $40 may apply
    $40 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services
    $15 to $40 copay [or 20% to 25% of the cost] for Medicare-covered outpatient X-rays
    $150 copay for Medicare-covered diagnostic radiology services
    $0 to $40 copay [or 25% of the cost] for Medicare-covered diagnostic procedures and tests
    $0 to $40 copay [or 25% of the cost] for Medicare-covered lab services
    If the doctor provides you services in addition to (Diagnostic Radiological Services ) separate cost sharing of $15 to $40 may apply
    ** Additional Benefits **
    Wellness/Education and Other Supplemental Benefits & Services
    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
  • 50% of the cost for supplemental education/wellness programs
    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.
    ** Cost **
    Premium and Other Important Information
    Package: 1 - MyOption Dental - High PPO:
    $16.40 monthly premium in addition to your $82 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    $1 500 plan coverage limit every year for these benefits.
    $50 deductible for these benefits.
    ** Important Information **
    Package: 1 - MyOption Dental - High PPO:
    $16.40 monthly premium in addition to your $82 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    $1 500 plan coverage limit every year for these benefits.
    $50 deductible for these benefits.
    ** Preventive Services **
    Dental Services
    Plan offers additional supplemental comprehensive dental benefits.
    0% of the cost for up to 2 supplemental oral exam(s) every year
    0% of the cost for up to 2 supplemental cleaning(s) every year
    0% of the cost for up to 1 supplemental dental x-ray(s) every year
    30% of the cost for supplemental preventive dental services
    55% to 75% of the cost for supplemental comprehensive dental services
    $1 500 plan coverage limit for supplemental dental benefits every year. This limit applies to both in-network and out-of-network benefits.

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    : : 2015 Plan Information Reminder Service
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    : : See 2014 Medicare Drug Plans
    : : 2014 Medicare Advantage Plans
    : : Browse Any 2014 Plan Formulary
    : : Find a 2014 Medicare Drug Plan by Drug Cost
    : : Compare 2014 Medicare Rx and Health Plans by Drug Costs
    : : Newsletter Sign-up
    : : 2015 Plan Info Reminder Service
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