| Essential Coverage PPO | Enhanced Coverage PPO | |
|---|---|---|
| Monthly Premium | $0 | $60 |
| Medical Deductible | $0 | $0 |
| Primary Care Copay | In-network $5 | Out-of-network 40% coinsurance | In-network $5 | Out-of-network 30% |
| Specialist Copay | In-network $40 | Out-of-network 40% coinsurance | In-network $35 | Out-of-network 30% |
| Routine Vision Coverage | One eye exam per calendar year: In-network $20 copay / Out-of-network 50% coinsurance. |
One eye exam per calendar year: In-network $20 copay / Out-of-network 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. | Plan provides coverage for contact lenses, eyeglass frames, and standard eyeglass lenses. Please refer to Summary of Benefits for details. |
| Hearing Coverage | In-network $0 copay / Out-of-network 50% coinsurance copay for routine hearing exams and hearing aid fitting and evaluations ($300 allowance every 3 years for hearing aids). | In-network $0 / Out-of-network 50% coinsurance for routine hearing exam and hearing aid fitting evaluation ($300 allowance every 3 years for hearing aids). |
| Preferred Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6) | $4 | $15 | $42 | $95 | 33% | $0 | $2 | $10 | $35 | $90 | 33% | $0 |
| Standard Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6) | $15 | $20 | $47 | $100 | 33% | $5 | $10 | $15 | $40 | $95 | 33% | $5 |
| Coverage Gap Coverage | 37% Generic Drugs / 25% Brand
|
37% Generic Drugs / 25% Brand |
| Out-of-pocket Max | $6,700 in-network, $10,000 combined | $6,700 in-network, $10,000 combined |
| Dental Coverage | In-network $10 | Out-of-network 50% coinsurance Visit Includes: Exam, Cleaning, 2 Bitewing X-Rays, Excludes Fluoride Treatments Medicare-Covered Benefits: Physician Specialist Copay In-network and Out-of-Network: Wrap-Around: $2,000 Max Plan Allowance per Contract (Calendar) Year After: 50% Coinsurance Palliative Emergency Treatment 50% Coinsurance Amalgam and Composite Fillings 50% Coinsurance Simple Extractions 50% Coinsurance Endodontics 50% Coinsurance Major Restorative (Crowns, Inlays, Onlays) 50% Coinsurance Prosthodontics 50% Coinsurance Adjustments and Repairs of Prosthetics Out-of-network Coinsurance Applied to Charges |
In-network $10 | Out-of-network 50% coinsurance Visit Includes: Exam, Cleaning, 2 Bitewing X-Rays, Excludes Fluoride Treatments Medicare-Covered Benefits: Physician Specialist Copay In-network and Out-of-Network: Wrap-Around: $2,000 Max Plan Allowance per Contract (Calendar) Year After: 50% Coinsurance Palliative Emergency Treatment 50% Coinsurance Amalgam and Composite Fillings 50% Coinsurance Simple Extractions 50% Coinsurance Endodontics 50% Coinsurance Major Restorative (Crowns, Inlays, Onlays) 50% Coinsurance Prosthodontics 50% Coinsurance Adjustments and Repairs of Prosthetics Out-of-network Coinsurance Applied to Charges |
|
For more details, please review the Summary of Benefits You can use these Star Ratings to compare our plan's performance to other plans. |
For more details, please review the Summary of Benefits You can use these Star Ratings to compare our plan's performance to other plans. |
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.
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.