- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $25 copay per visit
Out-of-network: $65 copay per visit
Out-of-network: 0-50% coinsurance
Emergency Room
$125 copay per visit (always covered)
Ambulance Coverage
In-network: $265 copay
Out-of-network: $265 copay
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: In-network: $0-40 copay
Out-of-network: 50% coinsurance
Medicare-covered lab services: In-network: $0 copay
Out-of-network: $65 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): In-network: $0-295 copay
Out-of-network: 50% coinsurance
Medicare-covered x-ray services: In-network: $40 copay
Out-of-network: 50% coinsurance
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: In-network: $0-350 copay per visit
Out-of-network: 50% coinsurance per visit
Hospitalization Coverage
Inpatient hospital-acute:
In-network: $350 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-network: 50% per stay
Inpatient hospital psychiatric:
In-network: $350 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-network: 50% per stay
Rehabilitation Coverage
Occupational therapy services:
In-network: $40 copay
Out-of-network: 50% coinsurance
Physical therapy and speech and language therapy services:
In-network: $40 copay
Out-of-network: 50% coinsurance
Urgent Care Coverage
$40 copay per visit (always covered)
Skilled Nursing Facility (SNF)
In-network: $10 per day for days 1 through 20
$203 per day for days 21 through 100
Out-of-network: 50% per stay
Mental Health Coverage
Medicare-covered individual sessions: In-network: $40 copay
Out-of-network: 50% coinsurance
Medicare-covered group sessions: In-network: $40 copay
Out-of-network: 40% coinsurance
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: 50% coinsurance
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: 50% coinsurance
Dental x-rays:
In-network: $0 copay
Out-of-network: 50% coinsurance
Vision Benefits
Eye exams:
Routine eye exams: In-network: $0 copay
Out-of-network: 50% coinsurance
Eyewear:
Contact Lenses: Not covered
Eyeglasses: Not covered
Hearing Benefits
Hearing exams:
Routine hearing exams: In-network: $0 copay
Out-of-network: 50% coinsurance
Hearing aids:
Hearing aids (all types): In-network: $0 copay
Out-of-network: $0 copay
Rx Drug Coverage - Preferred Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
24% coinsurance (30-day supply)
24% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$2.00 copay (30-day supply)
$6.00 copay (90-day supply)
Tier 2: Generic
$12.00 copay (30-day supply)
$36.00 copay (90-day supply)
Tier 3: Preferred Brand
24% coinsurance (30-day supply)
24% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$2.00 copay (30-day supply)
$6.00 copay (90-day supply)
Tier 2: Generic
$12.00 copay (30-day supply)
$36.00 copay (90-day supply)
Tier 3: Preferred Brand
24% coinsurance (30-day supply)
24% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Preferred Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
24% coinsurance (30-day supply)
24% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
More Additional Benefits
Plan Links
Ready to Enroll Online?
Or call and get free advice from licensed insurance agents
Looking for other plans in your area?