Essential Coverage PPO
|Benefit||Essential Coverage PPO|
|Monthly Premium Help||$0|
|Primary Care Copay||In $5 | Out $35|
|Specialist Copay||In $40 | Out $75|
|Routine Vision Coverage||
One eye exam per calendar year:|
In $20 copay / Out 50% coinsurance.
|Eyeglass, Contacts & Frames Coverage||Plan provides coverage for contact lenses, eyeglass frames, and standard eyeglass lenses. Please refer to Summary of Benefits for details.|
|Hearing Coverage||In $0 copay / Out $75 copay for routine hearing exams and hearing aid fitting and evaluations ($300 allowance every 3 years for hearing aids).|
|Preferred Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6) Help||$0 | $15 | $42 | $95 | 33% | $0|
|Standard Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6) Help||$15 | $20 | $47 | $100 | 33% | $5|
|Coverage Gap Coverage||Tiers 1 and 6|
|Out-of-pocket Max Help||$5,900|
|Monthly Dental Premium (Optional) Help||$33.30|
For more details, please review theSummary of Benefits
When you receive care covered by your benefit plan from a provider outside of our network, you are only responsible for paying your share of the cost, not the entire cost. Under this out-of-network coverage rule, your share of the cost may be higher for an out-of-network provider than for an in-network provider.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.
You must continue to pay your Medicare Part B premium.