You also continue to pay the Medicare Part B premium of $96.40.

$2000 out-of-pocket limit.
Contact the plan for services
that apply.

$2000 out-of-pocket limit.
Contact the plan for services
that apply.

Unless otherwise noted, out-of-network services not covered.

No referral required for network doctors, specialists, and hospitals.

You may have to pay a separate copay for certain doctor office visits.

You will pay less if you get
prior authorization or let the
plan know before you get an
out-of-network benefit.

For each benefit period:
Days 1 - 60: $1,024 deductible
Days 61 - 90: $256 per day
Days 91 - 150: $512 per lifetime reserve day.

Please call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days.

Lifetime reserve days can only be used once.

A "benefit period" starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins.  You must pay the inpatient hospital deductible for each benefit period.
There is no limit to the number of benefit periods you can have.

$0 copay

No limit to the number of days
covered by the plan each
benefit period.

Except in an emergency, your
doctor must tell the plan that
you are going to be admitted to
the hospital.

For hospital stays:

Days 1 - 7: $75 copay per day

Same deductible and copay as inpatient hospital care (see "Inpatient Hospital Care" above).

190-day limit in a Psychiatric Hospital.

$0 copay

You get up to 190 days in a
Psychiatric Hospital in a
lifetime.

Except in an emergency, your
doctor must tell the plan that
you are going to be admitted to
the hospital.

For hospital stays:
Days 1 - 7: $125 copay per day

Days 8 and beyond: $0 copay
per day

For each benefit period after at least a 3-day covered hospital stay:

Days 1 - 20: $0 per day
Days 21 - 100: $128 per day

A "benefit period" starts the day you go into a hospital or SNF. It ends when you go for 60 days without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.      

General
Prior authorization is required.

$0 copay for SNF services

100 days covered for each
benefit period

No prior hospital stay is
required.

General
Prior authorization is required.

$0 to $50 copay for SNF
benefits.

(includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.)

$0 copay.

General
Authorization rules may apply.

$0 copay for Medicare-covered
home health visits.

General
Authorization rules may apply.

$15 copay for home health
visits.

You pay part of the cost for outpatient drugs and inpatient respite care.

You must get care from a Medicare-certified hospice.

You must get care from a Medicare-certified hospice.

20% coinsurance

General
See "Routine Physical Exams," for more information.

$5 copay for each primary care
doctor visit for Medicare-covered benefits.

$10 copay for each specialist
visit for Medicare-covered
benefits.

General
See "Routine Physical Exams," for more information.

$10 copay for each primary
care doctor visit.

$15 copay for each specialist
visit.

20% coinsurance

Routine care not covered

20% coinsurance for manual manipulation of the spine to correct subluxation if you get it from a chiropractor or other qualified provider.

$10 copay for Medicare-covered visits.

Medicare-covered chiropractic
visits are for manual manipulation of the spine to correct a displacement or misalignment of a joint or body part.

$15 copay for chiropractic
benefits.

20% coinsurance

Routine care not covered.

20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs.

$10 copay for each
Medicare-covered visit.
Medicare-covered podiatry
benefits are for medically-necessary foot care.

$15 copay for podiatry
benefits.

50% coinsurance for most outpatient mental health services.

General
Authorization rules may apply.

$10 copay for each
Medicare-covered individual or group therapy visit.

General
Authorization rules may apply.

$15 copay for Mental Health benefits.

$15 copay for Mental Health
benefits with a psychiatrist.

General
Authorization rules may apply.

$10 copay for Medicare-covered individual or group visits.

General
Authorization rules may apply.

$15 copay for outpatient
substance abuse benefits.

20% coinsurance for the doctor

20% of outpatient facility

General
Authorization rules may apply.

$0 copay for each Medicare-covered ambulatory surgical center visit.

$0 copay for each Medicare-covered outpatient hospital facility visit.

General
Authorization rules may apply.

$75 copay for ambulatory
surgical center benefits.

$75 copay for outpatient
hospital facility benefits.

20% coinsurance

$25 copay for Medicare-covered ambulance benefits.

$25 copay for ambulance
benefits.

20% coinsurance for the doctor

20% of facility charge, or a set copay per emergency room visit.

You don't have to pay the emergency room copay if you are admitted to the hospital for the same condition within 3 days of the emergency room visit.

NOT covered outside the U.S. except under limited circumstances.

$50 copay for Medicare-covered emergency room visits

If you are admitted to the
hospital within 24-hour(s) for the same condition, you pay $0 for the emergency room visit

$100,000 limit for emergency
services outside the U.S. every year.

If you are admitted to the
hospital within 24-hour(s) for the same condition, you pay $0 for the emergency room visit

20% coinsurance, or a set copay

NOT covered outside the U.S. except under limited circumstances.

$10 copay for Medicare-covered urgently needed care visits

General
Authorization rules may apply.

$10 copay for Medicare-covered Occupational Therapy visits.

$10 copay for Medicare-covered Physical and/or Speech/Language
Therapy visits.

General
Authorization rules may apply.

$15 copay for Occupational
Therapy benefits.

$15 copay for Physical and/or
Speech/Language Therapy visits.

General
Authorization rules may apply.

10% of the cost for Medicare-covered items.

General
Authorization rules may apply.

20% of the cost for durable
medical equipment.

20% coinsurance

General
Authorization rules may apply.

10% of the cost for Medicare-covered items.

General
Authorization rules may apply.

20% of the cost for prosthetic devices.

(includes coverage for glucose monitors, test strips, lancets, screening tests, and self-management training)

20% coinsurance

$0 copay for Diabetes self-monitoring training.

$0 copay for Nutrition Therapy for Diabetes.

$10 copay for Diabetes supplies.

$10 copay for Diabetes self-monitoring training.

$15 copay for Nutrition Therapy for Diabetes.

$15 copay for Diabetes supplies.

20% coinsurance for diagnostic tests and X-rays
$0 copay for Medicare-covered lab services

Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most routine screening tests, like
checking your cholesterol.

$5 copay for Medicare-covered lab services.

$5 copay for Medicare-covered diagnostic procedures and tests.

$5 for Medicare-covered X-rays.

$5 copay for Medicare-covered
therapeutic radiology services.

$5 to $50 copay for Medicare-covered diagnostic radiology services.

10% of the cost for therapeutic
radiology services

$10 copay for diagnostic
procedures, tests, and lab
services.

$10 to $100 copay for
diagnostic radiology services

20% coinsurance

Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions.

$0 copay for Medicare-covered bone mass measurement.

$10 copay for Medicare covered bone mass measurement.

20% coinsurance

Covered when you are high risk or when you are age 50 and older.

$0 copay for Medicare-covered colorectal screenings.

$10 copay for colorectal screenings.

(Flu vaccine, Hepatitis B vaccine - for people with Medicare who are at risk, Pneumonia vaccine)

$0 copay for Flu and Pneumonia vaccines.

20% coinsurance for Hepatitis B vaccine.

You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information.

$0 copay for Flu and Pneumonia vaccines.

$0 copay for Hepatitis B vaccine.

No referral needed for Flu and pneumonia vaccines.

$0 copay for immunizations.

(for women with Medicare age 40 and older)

20% coinsurance

No referral needed.

Covered once a year for all women with Medicare age 40 and older.  One baseline mammogram covered for women with Medicare between age 35 and 39.

$0 copay for Medicare-covered screening mammograms.

$10 copay for screening
mammograms.

$0 copay for Pap smears

Covered once every 2 years. Covered once a year for women with Medicare at high risk.

$0 copay for Medicare-covered Pap smears and pelvic exams.

$10 copay for Pap smears and pelvic exams.

20% coinsurance for the digital rectal exam.

$0 for the PSA test; 20% coinsurance for other related services.

$0 copay for Medicare-covered prostate cancer screening.

$10 copay for prostate cancer screening.

20% coinsurance for dialysis

General
Authorization rules may apply. Out-of-area Renal Dialysis
services do not require
Authorization.

$10 copay for in-area dialysis

$15 copay for out-of-area dialysis

$0 copay for Nutrition Therapy for Renal Disease

General
Authorization rules may apply. Out-of-area Renal Dialysis
services do not require
Authorization.

$15 copay for Renal Disease.

$15 copay for Nutrition
Therapy.

Most drugs not covered.
(You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan.)

Drugs covered under Medicare Part B – General
Most drugs not covered.

10% of the cost for Part B – covered drugs (not including
Part B-covered chemotherapy
drugs).

10% of the cost for Part B-covered chemotherapy drugs.

Drugs Covered under Medicare Part D – General
This plan does not offer
prescription drug coverage.

Preventive dental services (such as cleaning) not covered.

General
Authorization rules may apply.

In general, preventive dental
benefits (such as cleaning) not
covered.

Routine hearing exams and hearing aids not covered.

20% coinsurance for diagnostic hearing exams.

In general, routine hearing
exams and hearing aids not
covered.

$10 copay for diagnostic
hearing exams

$15 copay for hearing exams.

20% coinsurance for diagnosis and treatment of diseases and conditions of the eye.

Routine eye exams and glasses not covered.

Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery.

Annual glaucoma screenings covered for people at risk.

$10 copay for one pair of eyeglasses or contact lenses after each cataract surgery.

$10 copay for exams to diagnose and treat diseases and conditions of the eye.

$0 copay for up to 1 pair(s) of
glasses every year

$0 copay for up to 1 pair(s) of
contacts every year

$100 limit for eye wear every year.

$15 copay for eye exams

$15 copay for eyewear

20% coinsurance for one exam within the first 6 months of your new Medicare Part B coverage

When you get Medicare Part B, you can get a one time physical exam within the first 6 months of your new Part B coverage. The coverage does not include lab tests.

$0 copay for routine exams.

Limited to 1 exam(s) every year.

$10 copay for routine exams.

Not covered.

This plan covers health/wellness education benefits.

• Written health education materials, including
• Newsletters
• Nutritional Training
• Nutritional benefit
• Smoking Cessation
• Nursing Hotline