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

If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more.

You pay $101 per month.

$1000 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 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.

$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

Days 8 and beyond: $0 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

100 days for each benefit period.

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.

$25 copay for SNF benefits.

$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.

$0 copay for each primary care doctor visit for Medicare-covered benefits.

$0 copay for each specialist
visit for Medicare-covered benefits.

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

$5 copay for each primary
care doctor visit.

$10 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.

$0 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.

$10 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.

$0 copay for each Medicare-covered visit.

Medicare-covered podiatry benefits are for medically necessary foot care.

$10 copay for podiatry
benefits.

50% coinsurance for most outpatient mental health services.

General
Authorization rules may apply.

$0 copay for each Medicare-covered Mental health visits.

General
Authorization rules may apply.

$10 copay for Mental Health
benefits.

$10 copay for Mental Health
benefits with a psychiatrist.

General
Authorization rules may apply.

$0 copay for Medicare-covered visits.

General
Authorization rules may apply.

$10 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

$0 copay for Medicare-covered ambulance benefits.

$25 copay for ambulance
benefits.

15. Emergency Care
(You may go to any emergency room if you reasonably believe you need emergency care.)

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.

$0 copay for Medicare-covered emergency room visits

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

(This is NOT emergency care, and in most cases, is out of the service area.)

20% coinsurance, or a set copay

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

$0 for Medicare-covered
urgently needed care visits.

(Occupational Therapy, Physical Therapy, Speech and Language Therapy)

20% coinsurance

General
Authorization rules may apply.

$0 copay for Medicare-covered
Occupational Therapy visits.

$0 copay for Medicare-covered Physical and/or Speech/Language Therapy visits.

General
Authorization rules may apply.

$10 copay for Occupational
Therapy benefits.

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

20% coinsurance

General
Authorization rules may apply.

$0 copay for Medicare-covered items.

General
Authorization rules may apply.

10% of the cost for durable
medical equipment.

20% coinsurance

General
Authorization rules may apply.

$0 copay for Medicare-covered items.

General
Authorization rules may apply.

10% of the cost of prosthetic
devices.

20. Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies
(includes coverage for glucose monitors, test strips, lancets, screening tests, and self-management training)

General
Authorization rules may apply.

$0 copay for Diabetes
self-monitoring training.

$0 copay for Nutrition Therapy
for Diabetes.

$0 copay for Diabetes
supplies.

General
Authorization rules may apply.

$10 copay for Diabetes self-monitoring training

10% of the cost for Diabetes supplies

$10 copay for Nutrition
Therapy for Diabetes.

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.

General
Authorization rules may apply.

$0 copay for Medicare-covered:

• lab services
• diagnostic procedures and tests
• X-rays
• diagnostic radiology services
• therapeutic radiology services

General
Authorization rules may apply.

$5 copay for diagnostic
procedures, tests, and lab services.

$10 copay for therapeutic radiology services

$10 copays for diagnostic radiology services

$25 copays 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.

25. Mammograms
(Annual Screening)

(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.

Up to 1 additional pap smear and pelvic exam(s) every year.

$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.

Covered once a year for all men with Medicare over age 50.

$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.

$0 copay for in and 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.

$10 copay for Renal Disease.

$10 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.

$0 copay for Part B-covered drugs and chemotherapy drugs.

Drugs covered under Medicare Part D

General
The plan uses a formulary.  The plan will send you the formulary. You can also see the formulary at http://www.nppdrugplans.com/ cgibin/phase2/formulary/index.pl
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).

The plan offers national
in-network prescription
coverage. This means that
you will pay the same 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 the 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 Network
PlatinumPremier PharmacyPharmacy for certain drugs.

The plan will pay for certain over-the-counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well.

Contact the plan for details.

You must go to certain
pharmacies for a very limited
number of drugs, due to the
special handling requirements
of these drugs. These drugs
are listed on the plan’s
website, formulary, and 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 copay
amount for that drug, you will
pay the actual cost, not the
higher copay amount.

$0 deductible.

Initial Coverage
You pay the following until total
yearly drug costs reach $2400:

Retail Pharmacy
Formulary Generic

• $9 copay for a one-month (31-day) supply of drugs from a
  non-preferred pharmacy
• $24 copay for a three-month (90-day) supply of drugs from a
  non-preferred pharmacy

Formulary Preferred Brand

• $25 copay for a one-month
  (31-day) supply of drugs from a non-preferred pharmacy
• $62.50 copay for a three-month (90-day) supply of drugs from a non-preferred
  pharmacy

Formulary Non-Preferred Brand

• $48 copay for a one-month (31-day) supply of drugs from a non-preferred pharmacy
• $144 copay for a three-month (90-day) supply of drugs from a non-preferred pharmacy

Specialty Products

• 25% coinsurance for a one-month (31-day) supply of drugs from a preferred pharmacy
• 33% coinsurance for a one-month (31-day) supply of drugs from a non-preferred pharmacy

Long Term Care Pharmacy
Formulary Generic

• $9 copay for a one-month (31-day) supply of drugs

Formulary Preferred Brand

• $25 copay for a one-month (31-day) supply of drugs

Formulary Non-Preferred Brand

• $48 copay for a one-month (31-day) supply of drugs

Specialty Products

• 33% coinsurance for a
  one-month (31-day) supply of drugs

Mail Order
Formulary Generic

• $9 copay for a one-month (31-day) supply of drugs
• $24 copay for a three-month (90-day) supply of drugs

Formulary Preferred Brand

• $25 copay for a one-month (31-day) supply of drugs
• $62.50 copay for a three-month (90-day) supply of drugs

Formulary Non-Preferred Brand

• $48 copay for a one-month (31-day) supply of drugs
• $144 copay for a three-month (90-day) supply of drugs

Coverage Gap
You pay the following:
The plan covers All Preferred
Generics through the gap.

Retail Pharmacy
Formulary Generic

• $9 copay for a one-month (31-day) supply of drugs you get at a preferred pharmacy
• $24 copay for a three-month (90-day) supply of drugs you get at a preferred pharmacy
• $9 copay for a one-month (31-day) supply of drugs you get at a non-preferred pharmacy
• $24 copay for a three-month (90-day) supply of drugs you get at a non-preferred pharmacy

Long Term Care Pharmacy
Formulary Generic

• $9 copay for a one-month (31-day) supply of drugs

Mail Order
Formulary Generic

• $9 copay for a one-month (31-day) supply of drugs
• $24 copay for a three-month (90-day) supply of drugs For all other covered drugs, after your total yearly drug costs reach $2400, you pay
  100% until your yearly
  out-of-pocket drug costs
  reach $4050.

Catastrophic Coverage
After your yearly out-of-pocket
drug costs reach $ 4050, you
pay the greater of:

• $ 2.25 copay for generic (including brand drugs treated as generic) and $ 5.60 opay for all other drugs, or
• 5% coinsurance.

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

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

Drugs covered under Medicare Part D

General
The plan uses a formulary.  The plan will send you the formulary. You can also see the formulary at http://www.nppdrugplans.com/ cgibin/phase2/formulary/index.pl
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).

The plan offers national
in-network prescription
coverage. This means that
you will pay the same 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 the 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 Network
PlatinumPremier PharmacyPharmacy for certain drugs.

The plan will pay for certain over-the-counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well.

Contact the plan for details.

You must go to certain
pharmacies for a very limited
number of drugs, due to the
special handling requirements
of these drugs. These drugs
are listed on the plan’s
website, formulary, and 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 copay
amount for that drug, you will
pay the actual cost, not the
higher copay amount.

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 pay more than the copay if you get your drugs at an out-of-network pharmacy.

Initial Coverage
You pay the following until total yearly drug costs reach $2400:

Pharmacy
Formulary Generic

• $9 copay for a one-month (31-day) supply of drugs

Formulary Preferred Brand

• $25 copay for a one-month (31-day) supply of drugs

Formulary Non-Preferred Brand

• $48 copay for a one-month (31-day) supply of drugs

Specialty Products

• 33% coinsurance for a
  one-month (31-day) supply of drugs

Coverage Gap
You pay the following:
Formulary Generic

• $9 copay for a one-month (31-day) supply of drugs

Catastrophic Coverage
After your yearly out-of-pocket
drug costs reach $4050, you
pay the greater of:

• $2.25 copay for generic (including brand drugs treated as generic) and $5.60 copay for all other drugs, or
• 5% coinsurance.

Preventive dental services (such as cleaning) not covered.

General
Authorization rules may apply.

$0 copay for Medicare-covered dental benefits.

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

General
Authorization rules may apply.

Routine hearing exams and hearing aids not covered.

20% coinsurance for diagnostic hearing exams.

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

$0 copay for diagnostic
hearing exams

$10 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.

$0 copay for diagnosis and treatment for diseases and conditions of the eye.

Up to 1 routine eye exam every two (2) years

$0 copay for one pair of eyeglasses or contact lenses after each cataract surgery.

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

$50 limit for eyewear every two years.

$10 copay for diagnosis and treatment for diseases and conditions of the eye.

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

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

$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