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$0

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.

$0 per visit.

$0 copay for e-visits, virtual check-ins, and remote patient monitoring with your PCP or Specialist.

For all other telehealth visits, copay is the same as corresponding in-person visit copay

$0 per day for Lab Services. Prior Authorization may be required.

$15 per annual visit

$0 per annual visit

$45 per visit.

$30 per day. Prior Authorization may be required.

$30 per day. Prior Authorization may be required.

Ultrasound: $60 per day; Others: $150 per day. Prior Authorization may be required.

Colonoscopies: $0; Other outpatient surgeries (Ambulatory Surgical Center, ASC): $210 per day; Other outpatient surgeries (Non-ASC): $310 per day. Prior Authorization may be required.

$30 per visit. Your copay for covered insulin will not exceed $35 per 30-day supply.

$0 per annual visit

$0 per annual visit

$0

$40 per visit
 

Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but, given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Urgent care copayment is NOT waived if admitted inpatient within 1 day.

$125 per visit. There is no limit to the number of visits in a plan year. Copay waived if admitted to observation or inpatient within 1 day for the same condition.

$395 per day for days 1-5. After day 5 you will pay $0 per day. Prior Authorization may be required.

$300 per one-way trip for medically necessary Ambulance Services. Prior authorization may be required for non-emergency transportation. Includes worldwide emergency transportation coverage.

$20 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. Additional acupuncture services are eligible for reimbursement under your Wellness Allowance.

$500 per calendar year. Reimbursement of fees to qualified health clubs, participation in instructional fitness classes, nutritional counseling, memory fitness activities, wellness programs, activity tracker (every 3 years), additional acupuncture services beyond Medicare coverage, and more.

$150 per calendar year. Reimbursement for program fees for weight loss programs such as Weight Watchers or hospital-based weight loss programs. Does not include meals or other program items, such as scales.

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. 

$140 every calendar quarter for the purchase of covered over-the-counter (OTC) items such as bandages and toothbrushes. Members receive an OTC card loaded quarterly with credit 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

$300 annual allowance through EyeMed; $300per calendar year for non-Eyemed provider. Use for standard eyeglasses (prescription lenses, frames, or a combination of lenses and frames) and/or contact lenses. The annual allowance may be used to purchase upgrades for Medicare-covered and/or therapeutic eyewear as well as routine/corrective eyewear.

The Dental Flex Advantage Spending Card is not offered with this plan.

$0

The plan pays up to the calendar year maximum of $3,000.

$0 copay; Two per year.

$0 copay; Once every 36 months (includes the initial dental history and charting of teeth). 

$0 copay; Two per year (when oral conditions indicate need).

20% coinsurance; Once every 60 months.

20% coinsurance; As needed.

20% coinsurance; Once every 24 months per surface per tooth.

50% coinsurance; Once every 6 months following active periodontal therapy, not to be combined with regular cleanings

50% coinsurance; Once per tooth. 

50% coinsurance; Once every 24 months per bridge or denture.

50% coinsurance; Once per arch within 84 months.

50% coinsurance; Once within 84 months per tooth (when teeth cannot be restored with regular filings due to fracture or decay).