Compare Plans
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Plan Name
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Champion Advantage
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Champion Connect
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Champion Select
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Champion Care
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Champion Choice
|
Champion Plus
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Champion Ally
|
|---|---|---|---|---|---|---|---|
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Plan Details
|
A Medicare Advantage Prescription Drug Health Maintenance Organization Point of Service Chronic Special Needs Plan (HMO-POS C-SNP) best suited for individuals with Chronic Kidney Disease (CKD), including those on dialysis, who qualify for Medicare but who do not qualify for Medicaid. |
A Medicare Advantage Prescription Drug Health Maintenance Organization Point of Service Chronic Special Needs Plan (HMO-POS C-SNP) best suited for individuals with Chronic Kidney Disease (CKD), including those on dialysis, who qualify for Medicare and may also receive assistance from Medicaid. |
A Medicare Advantage Prescription Drug Health Maintenance Organization Point of Service Chronic Special Needs Plan (HMO-POS C-SNP) best suited for individuals with Chronic Kidney Disease (CKD), including those on dialysis, who qualify for Medicare and Medicare's Extra Help program for Prescription Drugs also known as Low Income Subsidy (LIS), but do not qualify for Medicaid. |
This plan is a great choice for Medicare beneficiaries with a diagnosis of Cardiovascular Disease, Congestive Heart Failure, Chronic Heart Failure (CHF), Coronary Artery Disease (CAD), Cardiac Arrhythmias, or Diabetes who do not qualify for Medicare and do not receive institutional-level type of care (long-term care). |
This plan is a great choice for Medicare beneficiaries with a diagnosis of Cardiovascular Disease, Congestive Heart Failure, Chronic Heart Failure (CHF), Coronary Artery Disease (CAD), Cardiac Arrhythmias, or Diabetes who qualify for Medicare and do not receive institutional-level type of care (long-term care). |
Champion Plus is a Chronic Care Special Needs Plan (HMO C-SNP) and is a great choice for Medicare beneficiaries with a diagnosis of Schizophrenia, Schizoaffective, Bipolar, Major Depressive or Paranoid Disorders. This plan reduces the cost of prescription drugs while adding additional services and benefits. |
This plan is a great choice for Medicare beneficiaries that don't qualify for a Chronic Condition Special Needs plan (C-SNP). This plan reduces the cost of prescription drugs while adding additional services and benefits. |
|
Monthly Premium
|
$0 |
$0 |
$8.40 |
$0 |
$12 Your Cost with Medicare and Medicaid
$0 (with Extra Help) |
$12 Your Cost with Medicare and Medicaid
$0 (with Extra Help) |
$0 |
|
Monthly Premium
|
$0 |
$9.50 Your cost with Medicare and Medicaid
$0 (with Extra Help*) |
$9.50 |
$0 |
$9.50 Your Cost with Medicare and Medicaid
$0 (with Extra Help) |
$9.50 Your Cost with Medicare and Medicaid
$0 (with Extra Help) |
$0 |
|
Annual Plan Deductible
|
In-Network
No deductible Out-of-Network
No deductible |
In-Network
No plan deductible $257 Part B deductible. (This is the 2025 amount. The Plan will update this on its website once the 2026 amount is released.) Out-of-Network
No plan deductible $257 Part B deductible. (This is the 2025 amount. The Plan will update this on its website once the 2026 amount is released.) Your Cost with Medicare and Medicaid
No deductible |
In-Network
No deductible Out-of-Network
No deductible |
No Deductible |
No Plan Deductible $257 Part B Deductible (2025 cost sharing amounts and may change for 2026. Champion Health Plan will provide updated rates on its website when 2026 rates are released.) Your Cost with Medicare and Medicaid
No Deductible $0 for Part B Deductible |
No Plan Deductible $257 Part B Deductible (2025 cost sharing amounts and may change for 2026. Champion Health Plan will provide updated rates on its website when 2026 rates are released.) Your Cost with Medicare and Medicaid
No Deductible |
No Deductible |
|
Annual Maximum Out of Pocket (MOOP)
|
In-Network
$499 Out-of-Network
$499 |
In-Network
$9,250 Out-of-Network
$9,250 Your Cost with Medicare and Medicaid
$0 $0 for Part B Deductible |
In-Network
$499 Out-of-Network
$499 |
$199 |
$9,250 Your Cost with Medicare and Medicaid
$0 †if you have full Medicare benefits, you may pay $0 for your Medicare-covered services |
$9,250 Your Cost with Medicare and Medicaid
$0 |
$199 |
|
Inpatient Hospital
|
In-Network
$0 Copay Services may require authorization and a referral. Out-of-Network
Not covered |
In-Network
$1,676†* Deductible per Medicare-covered benefit period $0 Copay for days 1-60 $419 Copay for days 61-90 $838 Copay for each lifetime reserve day after day 90 for each benefit period (up to 60 days over your lifetime) 100% of all costs beyond the lifetime reserve days *These are 2025 cost sharing amounts and may change for 2026. Champion Health Plan will provide updated rates on its website when 2026 rates are released. Services may require authorization and a referral. Out-of-Network
Not covered Your Cost with Medicare and Medicaid
$0 †if you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization and a referral |
In-Network
$0 Per Stay Services may require authorization and a referral. Out-of-Network
Not covered |
$0 Per Stay Services may require authorization and a referral. |
$1,676 Deductible per benefit period $0 for days 1 - 60 $419 Copay for days 61 - 90 $838 Copay for each lifetime reserve day after day 90 for each benefit period (up to 60 days over your lifetime) 100% of all costs beyond the lifetime reserve days *These are 2025 cost sharing amounts and may change for 2026. Champion Health Plan will provide updated rates on its website when 2026 rates are released. Your Cost with Medicare and Medicaid
$0 †if you have full Medicare benefits, you may pay $0 for your Medicare-covered services Service may require authorization and referral. |
$1,676 Deductible per benefit period $0 for days 1 - 60 $419 Copay for days 61 - 90 $838 Copay for each lifetime reserve day after day 90 for each benefit period (up to 60 days over your lifetime) 100% of all costs beyond the lifetime reserve days *These are 2025 cost sharing amounts and may change for 2026. Champion Health Plan will provide updated rates on its website when 2026 rates are released. Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 †if you have full Medicare benefits, you may pay $0 for your Medicare-covered services Service may require authorization and referral. |
$0 Per Stay Services may require authorization and a referral. |
|
Outpatient Hospital and Ambulatory Surgery Centers (ASC)
|
In-Network
$100 Copay per visit outpatient hospital services $0 Copay for surgery in an ambulatory Surgery Center $0 Copay for outpatient hospital observation Services may require authorization and a referral. Out-of-Network
$100 Copay per visit outpatient hospital services $0 Copay for surgery in an ambulatory Surgery Center $0 Copay for outpatient hospital observation Services may require authorization and a referral. |
In-Network
20% of the Cost for outpatient hospital services 20% of the Cost for surgery in an Ambulatory Surgery Center 20% of the Cost for outpatient hospital observation Services may require authorization and a referral. Out-of-Network
20% of the Cost for outpatient hospital services $0 Copay for surgery in an Ambulatory Surgery Center 20% of the Cost for outpatient hospital observation Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay †if you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization and a referral. |
In-Network
$100 Copay for outpatient hospital services $0 Copay for surgery in an Ambulatory Surgery Center $0 Copay for outpatient hospital observation Services may require authorization and a referral. Out-of-Network
$100 Copay for outpatient hospital services $0 Copay for surgery in an Ambulatory Surgery Center $0 Copay for outpatient hospital observation Services may require authorization and a referral. |
$100 Copay for outpatient hospital services $0 Copay for surgery in an Ambulatory Surgery Center $0 Copay for outpatient hospital observation Services may require authorization and a referral. |
20% of the Cost for outpatient hospital services 20% of the Cost for surgery in an Ambulatory Surgery Center 20% of the Cost for outpatient hospital observation Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 †if you have full Medicare benefits, you may pay $0 for your Medicare-covered services Service may require authorization and referral. |
20% of the Cost for outpatient hospital services 20% of the Cost for surgery in an Ambulatory Surgery Center 20% of the Cost for outpatient hospital observation Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Service may require authorization and referral. |
$100 Copay for outpatient hospital services $0 Copay for surgery in an Ambulatory Surgery Center $0 Copay for outpatient hospital observation Services may require authorization and a referral. |
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Primary Care Providers
|
In-Network
$0 Copay Out-of-Network
$0 Copay |
In-Network
$0 Copay Out-of-Network
$0 Copay Your Cost with Medicare and Medicaid
$0 Copay |
In-Network
$0 Copay Out-of-Network
$0 Copay |
$0 Copay |
$0 Copay Your Cost with Medicare and Medicaid
$0 Copay |
$0 Copay Your Cost with Medicare and Medicaid
$0 Copay |
$0 Copay |
|
Specialists
|
In-Network
$0 Copay Authorization may be required for all services except nephrology. Out-of-Network
$0 Copay Authorization may be required for all services except nephrology. |
In-Network
20% of the Cost Authorization may be required for all services except nephrology. Out-of-Network
20% of the Cost Authorization may be required for all services except nephrology. Your Cost with Medicare and Medicaid
$0 Copay †if you have full Medicare benefits, you may pay $0 for your Medicare-covered services Authorization may be required. |
In-Network
$0 Copay Authorization may be required for all services except nephrology. Out-of-Network
$0 Copay Authorization may be required for all services except nephrology. |
$0 Copay Authorization may be required for all services except nephrology. |
20% of the Cost Authorization may be required for all services except nephrology. Your Cost with Medicare and Medicaid
$0 Copay †if you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization and referral. |
20% of the Cost Authorization may be required for all services except nephrology. Your Cost with Medicare and Medicaid
$0 Copay †if you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization and referral. |
$0 Copay Authorization may be required for all services except nephrology. |
|
Preventive Services (Medicare covered screenings)
|
In-Network
$0 Copay Out-of-Network
$0 Copay |
In-Network
$0 Copay Out-of-Network
$0 Copay Your Cost with Medicare and Medicaid
$0 Copay |
In-Network
$0 Copay Out-of-Network
$0 Copay |
$0 Copay |
$0 Copay Your Cost with Medicare and Medicaid
$0 Copay |
$0 Copay Your Cost with Medicare and Medicaid
$0 Copay |
$0 Copay |
|
Emergency Care (Hospital emergency department)
|
In-Network
$150 Copay Copay is waived if admitted to hospital within 24 hours for related health event Out-of-Network
$150 Copay Copay is waived if admitted to hospital within 24 hours for related health event |
In-Network
$115 Copay Copay is waived if admitted to hospital within 24 hours for related health event. Out-of-Network
$115 Copay Copay is waived if admitted to hospital within 24 hours for related health event. Your Cost with Medicare and Medicaid
$0 Copay Copay is waived if admitted to hospital within 24 hours for related health event †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services |
In-Network
$150 Copay Copay is waived if admitted to hospital within 24 hours for related health event Out-of-Network
$150 Copay Copay is waived if admitted to hospital within 24 hours for related health event |
$70 Copay Copay is waived if admitted to hospital within 24 hours for related health event |
$115 Copay Copay is waived if admitted to hospital within 24 hours for related health event. Your Cost with Medicare and Medicaid
$0 Copay Copay is waived if admitted to hospital within 24 hours for related health event. †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services |
$115 Copay Copay is waived if admitted to hospital within 24 hours for related health event. Your Cost with Medicare and Medicaid
$0 Copay Copay is waived if admitted to hospital within 24 hours for related health event. †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services |
$70 Copay Copay is waived if admitted to hospital within 24 hours for related health event. |
|
Worldwide Emergency Care
|
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Urgently Needed Care. |
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Urgently Needed Care. |
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Urgently Needed Care. |
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Urgently Needed Care. |
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Urgently Needed Care. |
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Urgently Needed Care. |
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Urgently Needed Care. |
|
Urgent Care Services (Non- hospital urgent care center)
|
In-Network
$0 Copay Out-of-Network
$0 Copay |
In-Network
$0 Copay Out-of-Network
$0 Copay Your Cost with Medicare and Medicaid
$0 Copay |
In-Network
$0 Copay Out-of-Network
$0 Copay |
$0 Copay |
$0 Copay Your Cost with Medicare and Medicaid
$0 Copay |
$0 Copay Your Cost with Medicare and Medicaid
$0 Copay |
$0 Copay |
|
Worldwide Urgently
Needed Care
|
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Emergency Care. |
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Emergency Care. |
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Emergency Care. |
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Emergency Care. |
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Emergency Care. |
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Emergency Care. |
Out-of-Network Only
$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Emergency Care. |
|
Diagnostic Services/Labs/Imaging
|
In-Network
$0 Copay Diagnostic tests and procedures and lab services may require authorization and a referral. Out-of-Network
$0 Copay Diagnostic tests and procedures and lab services may require authorization and a referral. |
In-Network
$0 Copay for lab services and X-rays 20%† of the cost for all other services Diagnostic tests and procedures and lab services may require authorization and a referral. Out-of-Network
$0 Copay for lab services and X-rays 20%† of the cost for all other services Diagnostic tests and procedures and lab services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay for lab services and X-rays $0 Copay for all other services †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Diagnostic tests and procedures and lab services may require authorization and a referral. |
In-Network
$0 Copay Diagnostic tests and procedures and lab services may require authorization and a referral. Out-of-Network
$0 Copay Diagnostic tests and procedures and lab services may require authorization and a referral. |
$0 Copay Diagnostic tests and procedures and lab services may require authorization and a referral. |
$0 Copay for lab services and X-Rays 20% of the Cost for all other services Diagnostic tests and procedures and lab services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay for lab services and X-rays $0 Copay for all other services †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Diagnostic tests and procedures and lab services may require authorization and a referral. |
$0 Copay for lab services and X-Rays 20% of the Cost for all other services Diagnostic tests and procedures and lab services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay for lab services and X-rays $0 Copay for all other services †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Diagnostic tests and procedures and lab services may require authorization and a referral. |
$0 Copay Diagnostic tests and procedures and lab services may require authorization and a referral. |
|
Hearing Services
|
In-Network
$0 Copay for Medicare-covered services every year Out-of-Network
$0 Copay for Medicare-covered services |
In-Network
$0 Copay for Medicare covered services every year Out-of-Network
$0 Copay for Medicare-covered services Your Cost with Medicare and Medicaid
$0 Copay for Medicare-covered services every year |
In-Network
$0 Copay for Medicare-covered services every year Out-of-Network
$0 Copay for Medicare-covered services |
$0 Copay for Medicare-covered services every year |
$0 Copay for Medicare-covered services every year |
$0 Copay for Medicare-covered services every year |
$0 Copay for Medicare covered services every year |
|
Hearing Services
|
In-Network
$0 Copay for one routine exam and one fitting/evaluation for hearing aids every year Out-of-Network
Not Covered |
In-Network
$0 Copay for one routine exam and one fitting/evaluation for hearing aids every year Out-of-Network
Not Covered Your Cost with Medicare and Medicaid
$0 Copay for one routine exam and one fitting/evaluation for hearing aids every year |
In-Network
$0 Copay for one routine exam and one fitting/evaluation for hearing aids every year Out-of-Network
Not Covered |
$0 Copay for one routine exam and one fitting/evaluation for hearing aids every year |
$0 Copay for one routine exam and one fitting/evaluation for hearing aids every year |
$0 Copay for one routine exam and one fitting/evaluation for hearing aids every year |
$0 Copay for one routine exam and one fitting/evaluation for hearing aids every year |
|
Hearing Services
|
In-Network
$149 Copay per hearing aid (all models) up to 2 aids every 3 years Out-of-Network
Not Covered |
In-Network
$149 Copay per hearing aid (all models) up to 2 aids every 3 years Out-of-Network
Not Covered Your Cost with Medicare and Medicaid
$149 Copay per in network hearing aid (all models) up to 2 aids every 3 years |
In-Network
$149 Copay per hearing aid (all models) up to 2 aids every 3 years Out-of-Network
Not Covered |
$149 Copay per hearing aid (all models) up to 2 aids every 3 years |
$149 Copay per hearing aid (all models) up to 2 aids every 3 years |
$149 Copay per hearing aid (all models) up to 2 aids every 3 years |
$149 Copay per hearing aid (all models) up to 2 aids every 3 years |
|
Dental Services
|
In-Network Only
$0 Copay for Preventive Dental Services and Medicare-covered dental services 20% to 40% of the Cost for Comprehensive Dental Services $3,000 yearly benefit coverage limit for preventive and comprehensive dental services combined. Comprehensive dental services may require authorization and a referral. |
In-Network Only
$0 Copay for Preventive Dental Services and Medicare-covered dental services 20% to 40% of the Cost for Comprehensive Dental Services $3,000 yearly benefit coverage limit for preventive and comprehensive dental services combined. Comprehensive dental services may require authorization and a referral. |
In-Network Only
$0 Copay for Preventive Dental Services and Medicare-covered dental services 20% to 40% of the Cost for Comprehensive Dental Services $3,000 yearly benefit coverage limit for preventive and comprehensive dental services combined. Comprehensive dental services may require authorization and a referral. |
$0 Copay for Preventive Dental Services and Medicare-covered dental services 20% to 40% of the Cost for Comprehensive Dental Services. Limitations may apply. $3,000 yearly benefit coverage limit for preventive and comprehensive dental services combined. Comprehensive dental services may require authorization and a referral. |
$0 Copay for Preventive Dental Services and Medicare-covered dental services 20% to 40% of the Cost for Comprehensive Dental Services. Limitations may apply. $3,000 yearly benefit coverage limit for preventive and comprehensive dental services combined. Comprehensive dental services may require authorization and a referral. |
$0 Copay for Preventive Dental Services and Medicare-covered dental services 20% to 40% of the Cost for Comprehensive Dental Services. Limitations may apply. $3,000 yearly benefit coverage limit for preventive and comprehensive dental services combined. Comprehensive dental services may require authorization and a referral. |
$0 Copay for Preventive Dental Services and Medicare-covered dental services 20% to 40% of the Cost for Comprehensive Dental Services. Limitations may apply. $3,000 yearly benefit coverage limit for preventive and comprehensive dental services combined. Comprehensive dental services may require authorization and a referral. |
|
Vision Services
|
In-Network
$0 Copay for a Medicare-covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) Out-of-Network
Not Covered |
In-Network
$0 Copay for Medicare-covered services every year Out-of-Network
Not Covered Your Cost with Medicare and Medicaid
$0 Copay for Medicare-covered services every year |
In-Network
$0 Copay for a Medicare-covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) Out-of-Network
Not Covered |
$0 Copay for a Medicare-covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) |
$0 Copay for a Medicare-covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) |
$0 Copay for a Medicare-covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) |
$0 Copay for a Medicare covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) |
|
Vision Services
|
In-Network
$0 Copay for (1) pair of Medicare-covered eyewear (eyeglasses (lenses and frames)) after a cataract surgery Out-of-Network
Not Covered |
In-Network
$0 Copay for (1) pair of Medicare-covered eyewear (eyeglasses (lenses and frames)) after a cataract surgery Out-of-Network
Not Covered Your Cost with Medicare and Medicaid
$0 Copay for (1) pair of Medicare-covered eyewear (eyeglasses (lenses and frames)) after a cataract surgery |
In-Network
$0 Copay for (1) pair of Medicare-covered eyewear (eyeglasses (lenses and frames)) after a cataract surgery Out-of-Network
Not Covered |
$0 Copay for (1) pair of Medicare covered eyewear (eyeglasses or contact lenses) after a cataract surgery |
$0 Copay for (1) pair of Medicare covered eyewear (eyeglasses or contact lenses) after a cataract surgery |
$0 Copay for (1) pair of Medicare covered eyewear (eyeglasses or contact lenses) after a cataract surgery |
$0 Copay for (1) pair of Medicare covered eyewear (eyeglasses or contact lenses) after a cataract surgery |
|
Vision Services
|
In-Network
$0 Copay for (1) routine eye exam, refraction up to (1) per year Out-of-Network
Not Covered |
In-Network
$0 Copay for one routine eye exam every year Out-of-Network
Not Covered Your Cost with Medicare and Medicaid
$0 Copay for one routine eye exam every year |
In-Network
$0 Copay for (1) routine eye exam, refraction up to (1) per year Out-of-Network
Not Covered |
$0 Copay for (1) routine eye exam, refraction up to (1) per year |
$0 Copay for (1) routine eye exam, refraction up to (1) per year |
$0 Copay for (1) routine eye exam, refraction up to (1) per year |
$0 Copay for (1) routine eye exam, refraction up to (1) per year |
|
Vision Services
|
In-Network
$335 Allowance for frames and lenses and upgrades every year Out-of-Network
Not Covered |
In-Network
$500 Allowance for eyeglasses (lenses and frames) and upgrades every year. Out-of-Network
Not Covered Your Cost with Medicare and Medicaid
$500 Allowance for eyeglasses (lenses and frames) and upgrades every year. |
In-Network
$335 Allowance for frames and lenses and upgrades every year Out-of-Network
Not Covered |
$335 Allowance for frames and lenses and upgrades every year |
$500 Allowance for frames and lenses and upgrades every year |
$500 Allowance for frames and lenses and upgrades every year |
$335 Allowance for eyeglasses (lenses and frames) and upgrades every year |
|
Mental Health Inpatient
|
In-Network
$100 Copay for days 1-10 $0 Copay for days 11-90 Services may require authorization and a referral. Out-of-Network
Not covered |
In-Network
$1,676 deductible per benefit period $0 for days 1 - 60 $419 copay for days 61 - 90 $838 copay for each lifetime reserve day after day 90 for each benefit period (up to 60 days over your lifetime) 100% of all costs beyond the lifetime reserve days *These are 2025 cost sharing amounts and may change for 2026. Champion Health Plan will provide updated rates on its website when 2026 rates are released. Services may require authorization and a referral. Out-of-Network
Not covered Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your in-network Medicare-covered services Services may require authorization and a referral. |
In-Network
$100 Copay for days 1-10 $0 Copay for days 11-90 Services may require authorization and a referral. Out-of-Network
Not covered |
$100 Copay for days 10 $0 Copay for days 11-90 Services may require authorization and a referral. |
$1,676 Deductible per benefit period $0 for days 1 - 60 $419 Copay for days 61 - 90 $838 Copay for each lifetime reserve day after day 90 for each benefit period (up to 60 days over your lifetime) 100% of all costs beyond the lifetime reserve days *These are 2025 cost sharing amounts and may change for 2026. Champion Health Plan will provide updated rates on its website when 2026 rates are released. Your Cost with Medicare and Medicaid
$0 †if you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization and referral. |
$1,676 Deductible per benefit period $0 for days 1 - 60 $419 Copay for days 61 - 90 $838 Copay for each lifetime reserve day after day 90 for each benefit period (up to 60 days over your lifetime) 100% of all costs beyond the lifetime reserve days *2025 Cost sharing amounts and may change for 2026. Champion Health Plan will provide updated rates on its website when 2026 rates are released. Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 †if you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization and referral. |
$100 Copay for days 1-10 $0 Copay for days 11-90 Services may require authorization and a referral. |
|
Mental Health Outpatient (Medicare-covered individual and group sessions)
|
In-Network
$0 Copay Services may require authorization and a referral. Out-of-Network
$0 Copay Services may require authorization and a referral. |
In-Network
$0 Copay Services may require authorization and a referral. Out-of-Network
$0 Copay Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay Services may require authorization and referral. |
In-Network
$0 Copay Services may require authorization and a referral. Out-of-Network
$0 Copay Services may require authorization and a referral. |
$0 Copay Services may require authorization and a referral. |
$0 Copay for group sessions 20% of the Cost for individual sessions Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization and a referral. |
$0 Copay Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay Services may require authorization and a referral. |
$0 Copay Services may require authorization and a referral. |
|
Skilled Nursing Facility
|
In-Network
$0 Copay for days 1-20 $218 Copay for days 21-100 Services may require authorization and a referral. Out-of-Network
Not covered |
In-Network
$0 Copay for days 1-20 $218 Copay for days 21-100 Services may require authorization and a referral. Out-of-Network
Not covered Your Cost with Medicare and Medicaid
$0 Copay for days 1-100 †If you have full Medicare benefits, you may pay $0 for your in-network Medicare-covered services Services may require authorization and a referral. |
In-Network
$0 Copay for days 1-20 $218 Copay for days 21-100 Services may require authorization and a referral. Out-of-Network
Not covered |
$0 Copay for days 1-20 $218 Copay for days 21-100 Services may require authorization and a referral. |
$0 Copay for days 1-20 $218 Copay for days 21-100 Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay for days 1-100 †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization and a referral. |
$0 Copay for days 1-20 $218 Copay for days 21-100 Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay for days 1-100 †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization and a referral. |
$0 Copay for days 1-20 $218 Copay for days 21-100 Services may require authorization and a referral. |
|
Outpatient Rehabilitation
|
In-Network
$0 Copay Services may require authorization and a referral. Out-of-Network
$0 Copay Services may require authorization and a referral. |
In-Network
20% of the Cost for physical and speech therapy services $0 Copay for occupational therapy services Services may require authorization and a referral. Out-of-Network
20% of the Cost for physical and speech therapy services $0 Copay for occupational therapy services Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay Services may require authorization and a referral. |
In-Network
$0 Copay Services may require authorization and a referral. Out-of-Network
$0 Copay Services may require authorization and a referral. |
$0 Copay Services may require authorization and a referral. |
$0 Copay for occupational therapy services 20% of the Cost for physical and speech therapy services Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay for physical, speech and occupational therapy sessions †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization and a referral. |
20% of the cost for physical and speech therapy services $0 for occupational therapy services Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay for physical, speech and occupational therapy sessions †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services. Services may require authorization and a referral. |
$0 Copay Services may require authorization and a referral. |
|
Ambulance Services
|
In-Network
20% of the Cost for Medicare covered air ambulance services $0 or $125 of the cost for Medicare-covered ground ambulance services Minimum cost share applies to non-emergency ground ambulance transport Authorization may be required for non-emergency services. Out-of-Network
20% of the Cost for Medicare covered air ambulance services $0 or $125 of the cost for Medicare-covered ground ambulance services Minimum cost share applies to non-emergency ground ambulance transport Authorization may be required for non-emergency services. |
In-Network
20%† of the Cost for Medicare-covered air ambulance services. $0 to $125 Copay for Medicare-covered ground ambulance services. Minimum cost share applies to non-emergency ground ambulance transports. Authorization may be required for non-emergency services. Out-of-Network
20%† of the Cost for Medicare-covered air ambulance services. $0 to $125 Copay for Medicare-covered ground ambulance services. Minimum cost share applies to non-emergency ground ambulance transports. Authorization may be required for non-emergency services. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare* benefits, you may pay $0 for your Medicare-covered services Authorization may be required for non-emergency services. |
In-Network
20% of the Cost for Medicare-covered air ambulance services $0 or $125 of the cost for Medicare-covered ground ambulance services Minimum cost share applies to non-emergency ground ambulance transport Authorization may be required for non-emergency services. Out-of-Network
20% of the Cost for Medicare-covered air ambulance services $0 or $125 of the cost for Medicare-covered ground ambulance services Minimum cost share applies to non-emergency ground ambulance transport Authorization may be required for non-emergency services. |
20% of the Cost for Medicare-covered air ambulance services $0 or $125 of the Cost for Medicare-covered ground ambulance services Minimum cost share applies to non-emergency ground ambulance transport Authorization may be required for non-emergency services. |
0% to 20% of the cost for air ambulance 0% to 20% of the cost for ground ambulance, not to exceed $125 copay Minimum cost share applies to non-emergency ambulance transport. Authorization may be required for non-emergency services. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Authorization may be required for non-emergency services. |
20% of the Cost for Medicare-covered air ambulance services 0% to 20% of the Cost for Medicare-covered ground ambulance services, not to exceed $125 copay Minimum cost share applies to non-emergency ground ambulance transport Authorization may be required for non-emergency services. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Authorization may be required for non-emergency services. |
20% of the Cost for Medicare-covered air ambulance services $0 or $125 of the Cost for Medicare-covered ground ambulance services Minimum cost share applies to non-emergency air and ground ambulance transport Authorization may be required for non-emergency services. |
|
Transportation
|
In-Network
$0 Copay 24 one-way plan-approved health related locations Out-of-Network
No Covered |
In-Network
$0 Copay 36 one-way plan-approved locations Out-of-Network
Not Covered |
In-Network
$0 Copay 24 one-way plan-approved health related locations Out-of-Network
No Covered |
$0 Copay 24 one-way plan-approved locations |
$0 Copay 36 one-way plan-approved locations |
$0 Copay 36 one-way plan-approved locations |
$0 Copay 24 one-way plan-approved locations |
|
Medicare Part B Drugs
|
In-Network
0% to 20% of the Cost You will pay no more than $24 Copay for a 30-day supply of insulins Out-of-Network
0% to 20% of the Cost You will pay no more than $24 for a 30-day supply of insulins |
In-Network
20%† of the cost You pay no more than $24 for a 30-day supply of insulin Out-of-Network
20%† of the cost You pay no more than $24 for a 30-day supply of insulin Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services |
In-Network
0% to 20% of the Cost You will pay no more than $24 Copay for a 30-day supply of insulins Out-of-Network
0% to 20% of the Cost You will pay no more than $24 for a 30-day supply of insulins |
0% to 20% Copay You pay no more than $24 for a 30-day supply of insulins. |
0% to 20% Copay You may no more than $35 for a 30-day supply of insulins. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services |
20% of the Cost You pay no more than $35 for a 30-day supply of insulin Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services |
0% to 20% of the Cost $0 to $24 Copay for 30-day supply Part B insulins. Prior authorization may be required. |
|
Dialysis
|
In-Network
$0 Copay Out-of-Network
$0 Copay You are eligible for reimbursement at 80% of the Medicare rate up to a maximum allowance of $25,000 per year for dialysis services received in Mexico. |
In-Network
$0 Copay Out-of-Network
20%† of the cost You are eligible for reimbursement at 80% of the Medicare rate up to a maximum allowance of $25,000 per year for dialysis services received in Mexico. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services |
In-Network
$0 Copay Out-of-Network
$0 Copay You are eligible for reimbursement at 80% of the Medicare rate up to a maximum allowance of $25,000 per year for dialysis services received in Mexico. |
20% of the Cost |
20% of the Cost Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services |
20% of the Cost Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services |
20% of the Cost |
|
Durable Medical Equipment (DME)
|
In-Network
DME, prosthetics, and medical supplies: $0 for items $100 or less 20% of the cost for items over $100 Services may require authorization. Out-of-Network
DME, prosthetics, and medical supplies: $0 for items $100 or less 20% of the cost for items over $100 Services may require authorization. |
In-Network
DME, Prosthetics, and Medical Supplies: $0 for items $100 or less 20% of the Cost for items over $100 Services may require authorization. Out-of-Network
DME, Prosthetics, and Medical Supplies: $0 for items $100 or less 20% of the Cost for items over $100 Services may require authorization. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization. |
In-Network
DME, prosthetics, and medical supplies: $0 for items $100 or less 20% of the cost for items over $100 Services may require authorization. Out-of-Network
DME, prosthetics, and medical supplies: $0 for items $100 or less 20% of the cost for items over $100 Services may require authorization. |
DME, Prosthetics, & Medical Supplies: $0 for items $100 or less 20% of the Cost for items over $100 Services may require authorization. |
DME, Prosthetics, & Medical Supplies: $0 for items $100 or less 20% of the Cost for items over $100 Services may require authorization. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization. |
DME, Prosthetics, & Medical Supplies: $0 for items $100 or less 20% of the Cost for items over $100 Services may require authorization. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization. |
DME, Prosthetics, & Medical Supplies: $0 for items $100 or less 20% of the Cost for items over $100 Services may require authorization. |
|
ESRD Care Transportation
|
In-Network
Eligible members receive up to 76 one-way trips to dialysis treatments. If transportation is not used and you are privately transported to dialysis service, private driver reimbursed at $0.67 per mile. The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify. You must be on any mode of dialysis. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for more information. Out-of-Network
Not covered |
In-Network
Eligible members receive up to 132 one-way trips to dialysis treatments. If transportation is not used and you are privately transported to dialysis service, private driver reimbursed at $0.67 per mile. The benefits mentioned area part of special supplemental program for the chronically ill. Not all members qualify. You must be on any mode of dialysis. Please see your Evidence of Coverage, Chapter 4 Section 2's Medical Benefit Chart for more information. Out-of-Network
Not covered Your Cost with Medicare and Medicaid
Eligible members receive up to 132 one-way trips to dialysis treatments. If transportation is not used and you are privately transported to dialysis service, private driver reimbursed at $0.67 per mile. The benefits mentioned area part of special supplemental program for the chronically ill. Not all members qualify. You must be on any mode of dialysis. Please see your Evidence of Coverage, Chapter 4 Section 2's Medical Benefit Chart for more information. |
In-Network
Eligible members receive up to 76 one-way trips to dialysis treatments. If transportation is not used and you are privately transported to dialysis service, private driver reimbursed at $0.67 per mile. The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify. You must be on any mode of dialysis. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for more information. Out-of-Network
Not covered |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
|
Over-the-Counter Items / Healthy Foods / Utilities Benefit
|
In-Network
$330 Allowance every (3) three months Eligible members pay $0 Copay for a debit card to use on over-the-counter items, healthy foods and produce, and assistance with utility costs. Remaining balance does not roll over to the next quarter. The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify. You must be on any mode of dialysis. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for more information. Out-of-Network
Not covered |
In-Network
$505 Allowance every (3) three months Eligible members pay $0 Copay for a debit card to use on over-the-counter items, healthy foods and produce,and assistance with utility costs. Remaining balance does not roll over to the next quarter. The benefits mentioned area part of special supplemental program for the chronically ill. Not all members qualify. You must be on any mode of dialysis. Please see your Evidence of Coverage, Chapter 4 Section 2's Medical Benefit Chart for more information. Out-of-Network
Not covered Your Cost with Medicare and Medicaid
$505 Allowance every (3) three months Eligible members pay $0 Copay for a debit card to use on over-the-counter items, healthy foods and produce,and assistance with utility costs. Remaining balance does not roll over to the next quarter. The benefits mentioned area part of special supplemental program for the chronically ill. Not all members qualify. You must be on any mode of dialysis. Please see your Evidence of Coverage, Chapter 4 Section 2's Medical Benefit Chart for more information. |
In-Network
$400 Allowance every (3) three months Eligible members pay $0 Copay for a quarterly allowance to use for healthy foods and produce, over-the-counter items, wellness products and/or assistance with utilities. Benefit does not rollover to the next period. The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify. You must be on any mode of dialysis. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for more information. Out-of-Network
Not covered |
$300 Allowance every (3) months $0 Copay for quarterly allowance to use for healthy foods and produce, over-the-counter items, wellness products and/or assistance with utilities. Benefit does not rollover to the next period. The benefits mentioned are a part of a special supplemental program for the chronically ill. Qualifying conditions include diabetes, cardiovascular disorders, and chronic heart failure. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for more information. |
$500 Allowance every (3) months $0 Copay for quarterly allowance to use for healthy foods and produce, over-the-counter items, wellness products and/or assistance with utilities. Benefit does not rollover to the next period. The benefits mentioned are a part of a special supplemental program for the chronically ill.Qualifying conditions include diabetes, cardiovascular disorders, and chronic heart failure. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for more information. |
$500 Allowance every (3) months $0 Copay for quarterly allowance to use for healthy foods and produce, over-the-counter items, wellness products and/or assistance with utilities. Benefit does not rollover to the next period. The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify. Qualifying conditions include Schizophrenia, Schizoaffective, Bipolar, Major Depressive or Paranoid Disorders. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for Special Supplemental Benefits for more information |
$330 Allowance every (3) months $0 Copay for quarterly allowance to use for over-the-counter items. Benefit does not rollover to the next period. Healthy foods and produce, wellness products and/or assistance with utilities benefits are a part of a special supplemental program for the chronically ill. Not all members qualify. Qualifying conditions include diabetes, cardiovascular disorders, stroke, overweight/obesity/metabolic syndrome, and cancer. This is not a full listing of eligible conditions. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for Special Supplemental Benefits for the Chronically Ill for a full listing of qualifying conditions. |
|
Over-the-Counter Items / Healthy Foods / Utilities Benefit
|
In-Network
$330 Allowance every (3) three months Eligible members pay $0 Copay for a debit card to use on over-the-counter items, healthy foods and produce, and assistance with utility costs. Remaining balance does not roll over to the next quarter. The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify. You must be on any mode of dialysis. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for more information. Out-of-Network
Not covered |
In-Network
$511 Allowance every (3) three months Eligible members pay $0 Copay for a debit card to use on over-the-counter items, healthy foods and produce,and assistance with utility costs. Remaining balance does not roll over to the next quarter. The benefits mentioned area part of special supplemental program for the chronically ill. Not all members qualify. You must be on any mode of dialysis. Please see your Evidence of Coverage, Chapter 4 Section 2's Medical Benefit Chart for more information. Out-of-Network
Not covered Your Cost with Medicare and Medicaid
$511 Allowance every (3) three months Eligible members pay $0 Copay for a debit card to use on over-the-counter items, healthy foods and produce,and assistance with utility costs. Remaining balance does not roll over to the next quarter. The benefits mentioned area part of special supplemental program for the chronically ill. Not all members qualify. You must be on any mode of dialysis. Please see your Evidence of Coverage, Chapter 4 Section 2's Medical Benefit Chart for more information. |
In-Network
$415 Allowance every (3) three months Eligible members pay $0 Copay for a quarterly allowance to use for healthy foods and produce, over-the-counter items, wellness products and/or assistance with utilities. Benefit does not rollover to the next period. The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify. You must be on any mode of dialysis. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for more information. Out-of-Network
Not covered |
$330 Allowance every (3) months $0 Copay for quarterly allowance to use for healthy foods and produce, over-the-counter items, wellness products and/or assistance with utilities. Benefit does not rollover to the next period. The benefits mentioned are a part of a special supplemental program for the chronically ill. Qualifying conditions include diabetes, cardiovascular disorders, and chronic heart failure. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for more information. |
$511 Allowance every (3) months $0 Copay for quarterly allowance to use for healthy foods and produce, over-the-counter items, wellness products and/or assistance with utilities. Benefit does not rollover to the next period. The benefits mentioned are a part of a special supplemental program for the chronically ill.Qualifying conditions include diabetes, cardiovascular disorders, and chronic heart failure. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for more information. |
$525 Allowance every (3) months $0 Copay for quarterly allowance to use for healthy foods and produce, over-the-counter items, wellness products and/or assistance with utilities. Benefit does not rollover to the next period. The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify. Qualifying conditions include Schizophrenia, Schizoaffective, Bipolar, Major Depressive or Paranoid Disorders. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for Special Supplemental Benefits for more information |
$330 Allowance every (3) months $0 Copay for quarterly allowance to use for over-the-counter items. Benefit does not rollover to the next period. Healthy foods and produce, wellness products and/or assistance with utilities benefits are a part of a special supplemental program for the chronically ill. Not all members qualify. Qualifying conditions include diabetes, cardiovascular disorders, stroke, overweight/obesity/metabolic syndrome, and cancer. This is not a full listing of eligible conditions. Please see your Evidence of Coverage, Chapter 4, Section 2's Medical Benefit Chart for Special Supplemental Benefits for the Chronically Ill for a full listing of qualifying conditions. |
|
Acupuncture
|
In-Network
$0 Copay Out-of-Network
$0 Copay |
In-Network
$0 copay Out-of-Network
$0 copay Your Cost with Medicare and Medicaid
$0 copay |
In-Network
$0 Copay Out-of-Network
$0 Copay |
$0 Copay |
$0 Copay Your Cost with Medicare and Medicaid
$0 Copay |
Not Covered
|
$0 Copay |
|
Acupuncture
|
Not Covered
|
Not Covered
|
Not Covered
|
$0 copay for up to 50 visits every year |
$0 Copay for up to 50 visits every year Your Cost with Medicare and Medicaid
$0 Copay for up to 50 visits every year |
Not Covered
|
$0 copay for up to 50 visits every year |
|
Acupuncture
|
Not Covered
|
Not Covered
|
Not Covered
|
$0 copay for up to 30 visits every year |
$0 Copay for up to 30 visits every year Your Cost with Medicare and Medicaid
$0 Copay for up to 30 visits every year |
Not Covered
|
$0 copay for up to 30 visits every year |
|
Chiropractic
|
In-Network
$0 Copay Out-of-Network
$0 Copay |
In-Network
$0 Copay Out-of-Network
$0 Copay |
In-Network
$0 Copay Out-of-Network
$0 Copay |
$0 copay |
$0 copay Your Cost with Medicare and Medicaid
$0 copay |
$0 copay Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 copay Services may require authorization and a referral. |
$0 Copay |
|
Chiropractic
|
Not Covered
|
Not Covered
|
Not Covered
|
$0 copay for up to 20 visits every year |
$0 copay for up to 20 visits every year Your Cost with Medicare and Medicaid
$0 copay for up to 20 visits every year |
Not Covered
|
$0 Copay for up to 20 visits every year |
|
Podiatry Services
(Medicare-covered services only)
|
In-Network
$0 Copay Services may require authorization and a referral. Out-of-Network
$0 Copay Services may require authorization and a referral. |
In-Network
20%† of the Cost †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services. Out-of-Network
20%† of the Cost †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services. |
In-Network
$0 Copay Services may require authorization and a referral. Out-of-Network
$0 Copay Services may require authorization and a referral. |
$0 Copay Services may require authorization and a referral. |
$0 Copay Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services Services may require authorization. |
20% of the Cost Services may require authorization and a referral. Your Cost with Medicare and Medicaid
$0 Copay †If you have full Medicare benefits, you may pay $0 for your Medicare-covered services. Services may require authorization. |
$0 Copay Services may require authorization and a referral. |
|
Hospice
|
Covered by Original Medicare |
Covered by Original Medicare |
Covered by Original Medicare |
Covered by Original Medicare |
Covered by Original Medicare |
Covered by Original Medicare |
Covered by Original Medicare |
|
Respite Service
|
In-Network
$0 Copay Up to 12 sessions every year. Out-of-Network
Not Covered |
In-Network
$0 Copay Up to 12 sessions every year. Out-of-Network
Not Covered |
In-Network
$0 Copay Up to 12 sessions every year. Out-of-Network
Not Covered |
$0 Copay Up to 12 times per year |
$0 Copay Up to 12 times per year |
Not Covered
|
Not Covered
|
|
Personal Emergency Response System (PERS)
|
In-Network
$0 Copay Out-of-Network
Not covered |
In-Network
$0 Copay Out-of-Network
Not covered |
In-Network
$0 Copay Out-of-Network
Not covered |
$0 Copay |
$0 Copay |
$0 Copay |
$0 Copay |
|
Silver&Fit Fitness Benefit
|
In-Network
$0 Copay for receiving up to $35 reimbursed each month on gym membership or fitness classes Out-of-Network
Not covered |
In-Network
$0 Copay for receiving up to $35 reimbursed each month on gym membership or fitness classes Out-of-Network
Not covered |
In-Network
$0 Copay for receiving up to $35 reimbursed each month on gym membership or fitness classes Out-of-Network
Not covered |
$0 Copay for receiving up to $35 reimbursed each month on gym membership or fitness classes |
$0 Copay for receiving up to $35 reimbursed each month on gym membership or fitness classes |
$0 Copay for receiving up to $35 reimbursed each month on gym membership or fitness classes |
$0 Copay for receiving up to $35 reimbursed each month on gym membership or fitness classes |
|
Remote Access Technologies (including Web/Phone-based technologies and Nursing
Hotline)
|
In-Network
$0 Copay You have access to a 24/7 specialized nephrology call center staffed by licensed nephrologists designed to assist members with ESRD related issues that may require diagnosis and treatment, questions, concerns and other resources relating to their ESRD dialysis care Out-of-Network
Not covered |
In-Network
$0 Copay You have access to a 24/7 specialized nephrology call center staffed by licensed nephrologists designed to assist members with ESRD related issues that may require diagnosis and treatment, questions, concerns and other resources relating to their ESRD dialysis care Out-of-Network
Not covered |
In-Network
$0 Copay You have access to a 24/7 specialized nephrology call center staffed by licensed nephrologists designed to assist members with ESRD related issues that may require diagnosis and treatment, questions, concerns and other resources relating to their ESRD dialysis care Out-of-Network
Not covered |
Not Covered
|
Not Covered
|
Not Covered
|
Not Covered
|
|
Annual Physical Exam
|
In-Network
$0 Copay for one (1) annual exam Out-of-Network
$0 Copay for one (1) annual exam |
In-Network
$0 Copay for one (1) annual exam Out-of-Network
$0 Copay for one (1) annual exam |
In-Network
$0 Copay for one (1) annual exam Out-of-Network
$0 Copay for one (1) annual exam |
$0 Copay for one (1) annual exam |
$0 Copay for one (1) annual exam |
$0 Copay for one (1) annual exam |
$0 Copay for one (1) annual exam |
|
Home and Bathroom Safety
Devices and Modifications
|
In-Network
$0 Copay for the provision of a shower chair Out-of-Network
Not covered |
In-Network
$0 Copay for the provision of a shower chair Out-of-Network
Not covered |
In-Network
$0 Copay for the provision of a shower chair Out-of-Network
Not covered |
$0 Copay for the provision of a shower chair |
$0 Copay for the provision of a shower chair |
$0 Copay for the provision of a shower chair |
$0 Copay for the provision of a shower chair |
|
Health Education
|
In-Network
$0 Copay for in-person or virtual interactive educational sessions with health professionals Out-of-Network
Not Covered |
In-Network
$0 Copay for in-person or virtual interactive educational sessions with health professionals Out-of-Network
Not Covered |
In-Network
$0 Copay for in-person or virtual interactive educational sessions with health professionals Out-of-Network
Not Covered |
$0 Copay |
$0 Copay |
$0 Copay |
$0 Copay |
| Prescription Drug Coverage | |||||||
|
Part D Deductible
|
In-Network
No deductible |
In-Network
$615 Deductible (does not apply to Tier 1, 2 and 6) Your cost with the Extra Help Program (for low-income subsidy)*
$0 Copay |
In-Network
$615 Deductible (does not apply to Tiers 1, 2 and 6) |
No deductible |
$615 deductible (does not apply to Tier 1, 2, and 6) |
$615 (does not apply to Tier 1 and Tier 6) |
No Deductible |
|
Initial Coverage
|
In-Network
Participating Retail Pharmacy: Up to a 30-day supply Mail Order: 100-day supply |
In-Network
Participating Retail Pharmacy: Up to a 30-day supply Mail Order: 100-day supply Your cost with the Extra Help Program (for low-income subsidy)*
Participating Retail Pharmacy: Up to a 30-day supply Mail Order: 100-day supply |
In-Network
Participating Retail Pharmacy: Up to a 30-day supply Mail Order: 100-day supply |
Participating Retail Pharmacy: Up to a 30-day supply Mail Order: 100-day supply |
Participating Retail Pharmacy: Up to a 30-day supply Mail Order: 100-day supply Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: Up to a 30-day supply Mail Order: 100-day supply |
Participating Retail Pharmacy: Up to a 30-day supply Mail Order: 100-day supply Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
Participating Retail Pharmacy: Up to a 30-day supply Mail Order: 100-day supply |
|
Tier 1: Preferred Generic
|
In-Network
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
In-Network
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay Your cost with the Extra Help Program (for low-income subsidy)*
Participating Retail Pharmacy / Mail Order: $0 Copay |
In-Network
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
|
Tier 2: Generic
|
In-Network
Participating Retail Pharmacy: $3 Copay Mail Order: $6 Copay |
In-Network
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay Your cost with the Extra Help Program (for low-income subsidy)*
Participating Retail Pharmacy / Mail Order: $0 Copay |
In-Network
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
Participating Retail Pharmacy: $3 Copay Mail Order: $6 Copay |
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
Participating Retail Pharmacy: $3 Copay Mail Order: $6 Copay |
|
Tier 3: Preferred Brand
|
In-Network
Participating Retail Pharmacy: $47 Copay Mail Order: $94 Copay |
In-Network
Participating Retail Pharmacy: 25% of the cost Mail Order: 25% of the cost Your cost with the Extra Help Program (for low-income subsidy)*
Participating Retail Pharmacy: Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay Mail Order: Generics: $0 or $3.20 or $10.20 Copay Brands: $0 or $9.80 or $25.30 Copay |
In-Network
Participating Retail Pharmacy: 25% of the Cost Mail Order: 25% of the Cost If you receive assistance under the Extra Help Program*, your cost will be
Participating Retail Pharmacy: Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay Mail Order: Generics: $0 or $3.20 or $10.20 Copay Brands: $0 or $9.80 or $25.30 Copay |
Participating Retail Pharmacy: $47 Copay Mail Order: $94 Copay |
Participating Retail Pharmacy: 25% of the Cost Mail Order: 25% of the Cost Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay Mail Order: Generics: $0 or $3.20 or $10.20 Copay Brands: $0 or $9.80 or $25.30 Copay |
Participating Retail Pharmacy: 25% of the Cost Mail Order: 25% of the Cost Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay Mail Order: Generics: $0 or $3.20 or $10.20 Copay Brands: $0 or $9.80 or $25.30 Copay |
Participating Retail Pharmacy: $47 Copay Mail Order: $94 Copay |
|
Tier 3: Preferred Brand
|
In-Network
Participating Retail Pharmacy: $47 Copay Mail Order: $94 Copay |
In-Network
Participating Retail Pharmacy: 25% of the cost Mail Order: 25% of the cost Your cost with the Extra Help Program (for low-income subsidy)*
Participating Retail Pharmacy / Mail Order: $0 Copay or $4.90 or $12.65 Copay |
In-Network
Participating Retail Pharmacy: 25% of the Cost Mail Order: 25% of the Cost If you receive assistance under the Extra Help Program*, your cost will be
Participating Retail Pharmacy / Mail Order: $0 Copay or $4.90 or $12.65 Copay |
Participating Retail Pharmacy: $47 Copay Mail Order: $94 Copay |
Participating Retail Pharmacy: 25% of the Cost Mail Order: 25% of the Cost Your Cost with Medicare and Medicaid
Participating Retail Pharmacy / Mail Order: $0 Copay or $4.90 or $12.65 Copay |
Participating Retail Pharmacy: 25% of the Cost Mail Order: 25% of the Cost Your Cost with Medicare and Medicaid
Participating Retail Pharmacy / Mail Order: $0 or $4.90 or $12.65 Copay |
Participating Retail Pharmacy: $47 Copay Mail Order: $94 Copay |
|
Tier 4: Non-Preferred Brand
|
In-Network
Participating Retail Pharmacy: $100 Copay Mail Order: $200 Copay |
In-Network
Participating Retail Pharmacy: 25% of the cost Mail Order: 25% of the cost Your cost with the Extra Help Program (for low-income subsidy)*
Participating Retail Pharmacy: Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay Mail Order: Generics: $0 or $3.20 or $10.20 Copay Brands: $0 or $9.80 or $25.30 Copay |
In-Network
Participating Retail Pharmacy: 25% of the Cost Mail Order: 25% of the Cost If you receive assistance under the Extra Help Program*, your cost will be
Participating Retail Pharmacy: Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay Mail Order: Generics: $0 or $3.20 or $10.20 Copay Brands: $0 or $9.80 or $25.30 Copay |
Participating Retail Pharmacy: $100 Copay Mail Order: $200 Copay |
Participating Retail Pharmacy: 25% of the Cost Mail Order: 25% of the Cost Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay Mail Order: Generics: $0 or $3.20 or $10.20 Copay Brands: $0 or $9.80 or $25.30 Copay |
Participating Retail Pharmacy: 25% of the Cost Mail Order: 25% of the Cost Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay Mail Order: Generics: $0 or $3.20 or $10.20 Copay Brands: $0 or $9.80 or $25.30 Copay |
Participating Retail Pharmacy: $100 Copay Mail Order: $200 Copay |
|
Tier 4: Non-Preferred Brand
|
In-Network
Participating Retail Pharmacy: $100 Copay Mail Order: $200 Copay |
In-Network
Participating Retail Pharmacy: 25% of the cost Mail Order: 25% of the cost Your cost with the Extra Help Program (for low-income subsidy)*
Participating Retail Pharmacy / Mail Order: Generics: $0 or $1.60 or $5.10 Copay Brands: $0 or $4.90 or $12.65 Copay |
In-Network
Participating Retail Pharmacy: 25% of the Cost Mail Order: 25% of the Cost If you receive assistance under the Extra Help Program*, your cost will be
Participating Retail Pharmacy / Mail Order: Generics: $0 or $1.60 or $5.10 Copay Brands: $0 or $4.90 or $12.65 Copay |
Participating Retail Pharmacy: $100 Copay Mail Order: $200 Copay |
Participating Retail Pharmacy: 25% of the Cost Mail Order: 25% of the Cost Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: Generics: $0 or $1.60 or $5.10 Copay Brands: $0 or $4.90 or $12.65 Copay Mail Order: Generics: $0 or $1.60 or $5.10 Copay Brands: $0 or $4.90 or $12.65 Copay |
Participating Retail Pharmacy: 25% of the Cost Mail Order: 25% of the Cost Your Cost with Medicare and Medicaid
Participating Retail Pharmacy / Mail Order: Generics: $0 or $1.60 or $5.10 Copay Brands: $0 or $4.90 or $12.65 Copay |
Participating Retail Pharmacy: $100 Copay Mail Order: $200 Copay |
|
Tier 5: Specialty Tier
|
In-Network
Participating Retail Pharmacy: 33% of the cost Mail Order: A 100-day supply is not available in Tier 5 |
In-Network
Participating Retail Pharmacy: 25% of the cost Mail Order: A 100-day supply is not available in Tier 5 Your cost with the Extra Help Program (for low-income subsidy)*
Participating Retail Pharmacy: Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay Mail Order: A 100-day supply is not available in Tier 5 |
In-Network
Participating Retail Pharmacy: 25% of the cost Mail Order: A 100-day supply is not available in Tier 5 If you receive assistance under the Extra Help Program*, your cost will be
Participating Retail Pharmacy: Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay Mail Order: A 100-day supply is not available in Tier 5 |
Participating Retail Pharmacy: 33% of the Cost Mail Order: A 100-day supply is not available in Tier 5 |
Participating Retail Pharmacy: 25% of the Cost Mail Order: A 100-day supply is not available in Tier 5 Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay Mail Order: A 100-day supply is not available in Tier 5 |
Participating Retail Pharmacy: 25% of the Cost Mail Order: A 100-day supply is not available in Tier 5 Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay Mail Order: A 100-day supply is not available in Tier 5 |
Participating Retail Pharmacy: 33% of the Cost Mail Order: A 100-day supply is not available in Tier 5 |
|
Tier 5: Specialty Tier
|
In-Network
Participating Retail Pharmacy: 33% of the cost Mail Order: A 100-day supply is not available in Tier 5 |
In-Network
Participating Retail Pharmacy: 25% of the cost Mail Order: A 100-day supply is not available in Tier 5 Your cost with the Extra Help Program (for low-income subsidy)*
Participating Retail Pharmacy: Generics: $0 or $1.60 or $5.10 Copay Brands: $0 or $4.90 or $12.65 Copay Mail Order: A 100-day supply is not available in Tier 5 |
In-Network
Participating Retail Pharmacy: 25% of the cost Mail Order: A 100-day supply is not available in Tier 5 If you receive assistance under the Extra Help Program*, your cost will be Generics: $0 or $1.60 or $5.10 Copay Brands: $0 or $4.90 or $12.65 Copay |
Participating Retail Pharmacy: 33% of the Cost Mail Order: A 100-day supply is not available in Tier 5 |
Participating Retail Pharmacy: 25% of the Cost Mail Order: A 100-day supply is not available in Tier 5 Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: Generics: $0 or $1.60 or $5.10 Copay Brands: $0 or $4.90 or $12.65 Copay Mail Order: A 100-day supply is not available in Tier 5 |
Participating Retail Pharmacy: 25% of the Cost Mail Order: A 100-day supply is not available in Tier 5 Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: Generics: $0 or $1.60 or $5.10 Copay Brands: $0 or $4.90 or $12.65 Copay Mail Order: A 100-day supply is not available in Tier 5 |
Participating Retail Pharmacy: 33% of the Cost Mail Order: A 100-day supply is not available in Tier 5 |
|
Tier 6: Select Care Drugs
|
In-Network
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
In-Network
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay Your cost with the Extra Help Program (for low-income subsidy)*
Participating Retail Pharmacy / Mail Order: $0 Copay |
In-Network
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay Your Cost with Medicare and Medicaid
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
Participating Retail Pharmacy: $0 Copay Mail Order: $0 Copay |
|
Catastrophic Coverage
(after you or others on your behalf pay $2,100)
|
In-Network
During this stage, the plan pays the full cost for your covered Part D drugs. |
During this stage, the plan pays the full cost for your covered Part D drugs. |
In-Network
During this stage, the plan pays the full cost for your covered Part D drugs. |
During this stage, the plan pays the full cost for your covered Part D drugs. |
During this stage, the plan pays the full cost for your covered Part D drugs. |
During this stage, the plan pays the full cost for your covered Part D drugs. |
During this stage, the plan pays the full cost for your covered Part D drugs. |
|
Important message about what you pay for insulin
|
In-Network
At retail pharmacy locations, you won't pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. You will not pay more than $35 for a one-month supply of insulin on Tier 5. For mail order, you won't pay more than $40 for a three month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. Long term supplies of insulins in Tier 5 are not available through mail order. |
In-Network
At retail pharmacy locations, you won't pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6 and no more than $35 for a one-month supply of insulin on Tier 5, even if you haven't paid your deductible. For mail order, you won't pay more than $40 for a three month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. Long term supplies of insulins in Tier 5 are not available through mail order. Your cost with Extra Help*
Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay |
In-Network
At retail pharmacy locations, you won't pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. You will not pay more than $35 for a one-month supply of insulin on Tier 5, even if you haven't paid your deductible. For mail order, you won't pay more than $40 for a three month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. Long term supplies of insulins in Tier 5 are not available through mail order. |
At retail pharmacy locations, you won't pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. You will not pay more than $35 for a one-month supply of insulin on Tier 5. For mail order, you won't pay more than $40 for a three month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. Long term supplies of insulins in Tier 5 are not available through mail order. |
You won't pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6 and no more than $35 for a one-month supply of insulin on Tier 5, even if you haven't paid your deductible. Your cost with Extra Help*
Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay |
You won't pay more than $20 for a one-month supply or $60 for a three month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6 and no more than $35 for a one-month supply of insulin on Tier 5, even if you haven't paid your deductible. Your Cost with Medicare and Medicaid
Generics: $0 or $4.80 or $15.30 Copay Brands: $0 or $14.70 or $37.95 Copay |
At retail pharmacy locations, you won't pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. You will not pay more than $35 for a one-month supply of insulin on Tier 5. For mail order, yoau won't pay more than $40 for a three month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. Long term supplies of insulins in Tier 5 are not available through mail order. |
|
Important message about what you pay for insulin
|
In-Network
At retail pharmacy locations, you won't pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. You will not pay more than $35 for a one-month supply of insulin on Tier 5. For mail order, you won't pay more than $40 for a three month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. Long term supplies of insulins in Tier 5 are not available through mail order. |
In-Network
At retail pharmacy locations, you won't pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6 and no more than $35 for a one-month supply of insulin on Tier 5, even if you haven't paid your deductible. For mail order, you won't pay more than $40 for a three month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. Long term supplies of insulins in Tier 5 are not available through mail order. Your cost with Extra Help*
Generics: $0 or $1.60 or $5.10 Copay Brands: $0 or $4.90 or $12.65 Copay |
In-Network
At retail pharmacy locations, you won't pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. You will not pay more than $35 for a one-month supply of insulin on Tier 5, even if you haven't paid your deductible. For mail order, you won't pay more than $40 for a three month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. Long term supplies of insulins in Tier 5 are not available through mail order. |
At retail pharmacy locations, you won't pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. You will not pay more than $35 for a one-month supply of insulin on Tier 5. For mail order, you won't pay more than $40 for a three month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. Long term supplies of insulins in Tier 5 are not available through mail order. |
You won't pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6 and no more than $35 for a one-month supply of insulin on Tier 5, even if you haven't paid your deductible. Your cost with Extra Help*
Generics: $0 or $1.60 or $5.10 Copay Brands: $0 or $4.90 or $12.65 Copay |
You won't pay more than $20 for a one-month supply or $60 for a three month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6 and no more than $35 for a one-month supply of insulin on Tier 5, even if you haven't paid your deductible. Your Cost with Medicare and Medicaid
Generics: $0 or $1.60 or $5.10 Copay Brands: $0 or $4.90 or $12.65 |
At retail pharmacy locations, you won't pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. You will not pay more than $35 for a one-month supply of insulin on Tier 5. For mail order, yoau won't pay more than $40 for a three month supply of each insulin product covered by our plan on Tiers 1, 2, 3, 4 and 6. Long term supplies of insulins in Tier 5 are not available through mail order. |
|
Important message about what you pay for vaccines
|
In-Network
Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information. |
In-Network
Our plan covers most Part D vaccines at no cost to you, even if you haven't paid your deductible. Call Member Services for more information. Your cost with Extra Help*
Our plan covers most Part D vaccines at no cost to you, even if you haven't paid your deductible. Call Member Services for more information. |
In-Network
Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information. |
In-Network
Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information. |
In-Network
Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information. |
In-Network
Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information. |
In-Network
Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information. |
|
*Extra Help Program
|
If you meet federal low income limits, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |
If you have Medicare, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |
If you meet federal low income limits, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |
If you meet federal low income limits, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |
If you have Medicare, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |
If you meet federal low income limits, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |
If you meet federal low income limits, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |
|
*Extra Help Program
|
If you meet federal low income limits, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |
If you have Medicare, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |
If you meet federal low income limits, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |
If you meet federal low income limits, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |
If you meet federal low income limits, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |
If you have Medicaid, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low- income subsidy amounts for all of your Part D drugs. |
If you meet federal low income limits, you qualify for the Extra Help program that assists individuals with Part D cost shares, including deductibles. You may pay $0 for your Part D premium, deductible and no more than the low income subsidy amounts for all of your Part D drugs. |