Essential Coverage PPO
This plan is a Medicare Advantage plan, also known as Medicare Part C. It covers all of your Medicare Part A and Part B healthcare costs, and your Part D prescription drug costs—all in one plan! In many cases, these plans also include additional benefits beyond what original Medicare covers. View plan details, with premium, deductible, and your pay limits for covered services.
|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.