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Gap Coverage: There is no Gap Coverage Stage for this plan's drug coverage. After the Initial Coverage (IC) stage, the members will move on to the Catastrophic Coverage (CC) stage.

Catastrophic Coverage: Once you've spent $2,000 in out-of-pocket prescription costs you are in the Catastrophic Coverage Stage. If you reach the Catastrophic Coverage Stage, you pay nothing for covered Part D drugs and for excluded drugs that are covered under our enhanced benefit.

$0 for 30-day retail supply

$0 for 30-day retail supply

Part B: $35/month (Other Part B Drugs: up to 20%)

Part D: Your copay for covered insulin will not exceed $35 per 30-day supply regardless of the drug tier. This means that your copay is the Tier 1, Tier 2, Tier 3, or Tier 4 copay, or $35 per 30-day supply, whichever is lower.

In-Network: $0; Out-of-Network: $50 per visit.

In-Network: Includes Medicare covered services and additional telehealth services. $0 copay for e-visits, virtual visits, and remote patient monitoring with your PCP or Specialist. For all other telehealth visits, copay is the same as corresponding in-person visit copay.

Out-of-Network: Includes Medicare covered services; cost share is the same as corresponding in-person visit copay. Additional telehealth services not covered. 

In-Network: $0. Prior Authorization may be required for in-network services; Out-of-Network: 40% coinsurance.

In-Network: $0 per annual visit; Out-of-Network $65 per annual visit

In-Network: $0 per annual visit; Out-of-Network: $65 per annual visit after deductible

In-Network: $45 per visit; Out-of-Network: $65 per visit.

In-Network: $10 per day. Prior Authorization may be required for in-network services; Out-of-Network: 40% coinsurance.

In-Network: $40 per day. Prior Authorization may be required for in-network services; Out-of-Network: 40% coinsurance.

In-Network: Ultrasound: $60 per day; Others: $150 per day; Prior Authorization may be required for in-network services; Out-of-Network: 40% coinsurance

In-Network: Colonoscopy: $0; Others (Ambulatory Surgical Center, ASC): $295 per day; Others (Non-ASC): $395 per day; Prior Authorization may be required for in-network services 

Out-of-Network: 40% coinsurance

In-Network: $30 per visit; Out-of-Network: 40% coinsurance. Prior authorization may be required.

In-Network: $0; Out-of-Network: 40% coinsurance

In-Network: $0; Out-of-Network: 40%

In-Network: $0; Out-of-Network: 40% coinsurance

$40 per visit for urgently needed services provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgent care copayment is NOT waived if admitted inpatient within 1 day.

$125 per visit. Copay waived if admitted to observation or inpatient within 1 day for the same condition.

In-Network: $395 per day for days 1-5; $0 after day 5; Prior Authorization may be required for in-network services; Out-of-Network: 40% coinsurance

In-Network and Out-of-Network: $325 per one-way trip. Coverage for medically necessary Ambulance Services. Prior authorization may be required for non-emergency transportation. Includes worldwide emergency transportation coverage.

In-Network: $20 per visit
Out-of-Network: $65 per visit 

Covers up to 12 visits in 90 days for members with chronic lower back pain. 8 additional visits covered for those demonstrating an improvement. No more than 20 visits administered annually.

$250 per calendar year. Reimbursement of fees to qualified health clubs, participation in instructional fitness classes, participation in online instructional fitness classes or membership fees for online fitness subscriptions, such as Peloton, nutritional counseling ,memory fitness activities, wellness programs, additional acupuncture services beyond Medicare coverage, and more. See Evidence of Coverage.

Not included.

You receive a SilverSneakers fitness membership at no additional cost giving you access to 15,000+ gyms nationwide, trained instructors, classes and health and nutrition tips with exercise videos. SilverSneakers includes a fitness membership with access to all basic amenities plus group exercise classes designed to improve muscular strength and endurance, mobility, flexibility, range of motion, balance, agility and coordination. At-home exercise kits are available for SilverSneakers members, including those who have a disability, are recovering from a medical procedure or illness, live in a rural area or experience traffic difficulties and can’t make it to a fitness center. See your Evidence of Coverage for more information. 

$102 per calendar quarter to spend on Medicare approved health-related OTC items. Members receive quarterly credit on the Flex Advantage spending card to use towards covered OTC items at participating retailers and plan approved online stores. Unused quarterly balances do not rollover. You may also purchase OTC hearing aids using your OTC benefits. See Evidence of Coverage (EOC) for more information.

You are eligible for up to 2 covered hearing aids per year, 1 aid per ear. To be covered, the hearing aids must be on the Hearing Care Solutions formulary and must be purchased through Hearing Care Solutions. Different copays apply.

$250 Standard Level

$475 Superior Level

$650 Advanced Level

$850 Advanced Plus Level

$1,150 Premier Level

Out-of-Network: Hearing aid must be ordered only through Hearing Care Solutions

$250 allowance per calendar year for standard eyeglasses (prescription lenses, frames, or a combination of lenses and frames) and/or contact lenses purchased from any provider. The annual allowance may be used to purchase upgrades for Medicare-covered and/or therapeutic eyewear as well as routine/corrective eyewear.

Access PPO members receive a yearly dental benefit amount of $1,500, which can be used to pay for any non-cosmetic and non-Medicare-covered dental procedure. The full amount is loaded onto your Flex Advantage spending card at the beginning of the year. The balance does not carry over, so try to use it all before the end of the year. *Restrictions apply. Consult your Evidence of Coverage (EOC) for details.

Not Applicable - Dental Covered Under Flex Advantage Spending Card

Not Applicable - Dental Covered Under Flex Advantage Spending Card

Not Applicable - Dental Covered Under Flex Advantage Spending Card

Not Applicable - Dental Covered Under Flex Advantage Spending Card

Not Applicable - Dental Covered Under Flex Advantage Spending Card

Not Applicable - Dental Covered Under Flex Advantage Spending Card

Not Applicable - Dental Covered Under Flex Advantage Spending Card

Not Applicable - Dental Covered Under Flex Advantage Spending Card

Not Applicable - Dental Covered Under Flex Advantage Spending Card

Not Applicable - Dental Covered Under Flex Advantage Spending Card

Not Applicable - Dental Covered Under Flex Advantage Spending Card

Not Applicable - Dental Covered Under Flex Advantage Spending Card

Not Applicable - Dental Covered Under Flex Advantage Spending Card