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April 1 – September 30: Monday – Friday, 8 am – 8 pm
October 1 – March 31: Monday – Sunday, 8 am – 8 pm

Plan Details
Champion Advantage
Champion Connect
Champion Select
Monthly Premium $0 $41 $41
Monthly Premium $0 $32 $32
Annual Plan Deductible No Deductible No Deductible No Deductible
Annual Maximum Out of Pocket (MOOP) $5,495 $8,300 $4,495
Annual Maximum Out of Pocket (MOOP) $5,495 $8,375 $4,575
Inpatient Hospital $0 Copay
Services may require authorization and a referral.

20% of the Cost of Part B provider services

$1,600* deductible per benefit period

$0* for days 1 through 60 $400* copay per day for days 61 through 90

$800* copay per 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 2023 cost-sharing amounts and may change for 2024. Champion Health Plan will provide updated rates as soon as they are released.

Services may require authorization and a referral.

$0 Copay

Services may require authorization and a referral.

Outpatient Hospital and Ambulatory Surgery Centers (ASC)

$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

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.

Primary Care Providers $0 Copay $0 Copay $0 Copay
Specialists

$0 Copay

Authorization may be required for all services except nephrology.

$0 Copay

Authorization may be required for all services except nephrology.

$0 Copay

Authorization may be required for all services except nephrology.

Preventive Services
(Medicare Covered Screenings)
$0 Copay $0 Copay $0 Copay
Emergency Care
(Hospital Emergency Department)

$100 Copay

Copay is waived if admitted to hospital within 24 hours for related health event

$95 Copay

Copay is waived if admitted to hospital within 24 hours for related health event

$100 Copay

Copay is waived if admitted to hospital within 24 hours for related health event

Urgent Care Services
(Non-hospital Urgent Care Center)
$0 Copay $0 Copay $0 Copay
Diagnostic Services/ Labs/Imaging
  • Diagnostic tests and procedures
  • X-Rays
  • Lab Services
  • Diagnostic radiology services (such as MRI, CT Scans)
  • Therapeutic radiology services (such as radiation treatment for cancer)

$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.

$0 Copay

Diagnostic tests and procedures and lab services may require authorization and a referral.

Hearing Services
  • Medicare-covered services
  • Routine Hearing Exam
  • Fitting/Evaluation for Hearing Aid
  • Hearing Aid

$0 Copay for Medicare-covered services every year

$0 Copay for one routine exam and one fitting/evaluation for hearing aids every year

$149 Copay per hearing aid (all models) up to 2 aids every 3 years

$0 Copay for Medicare-covered services every year

$0 Copay for one routine exam and one fitting/ evaluation for hearing aids every year

$150 Copay per hearing aid (all models) up to 2 aids every 3 years

$0 Copay for Medicare-covered services every year

$0 Copay for one routine exam and one fitting/evaluation for hearing aids every year

$150 Copay per hearing aid (all models) up to 2 aids every 3 years

Dental Services

$0 Copay for Preventive Dental Services and Medicare-covered dental services

20% to 40% of the Cost for Comprehensive Dental Services with a $3,000 yearly benefit coverage limit

$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 with a $3,000 yearly benefit coverage limit

$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 with a $3,000 yearly benefit coverage limit
$3,000 yearly benefit coverage limit for preventive and comprehensive dental services combined
Comprehensive dental services may require authorization and a referral
Vision Services
  • Medicare covered eye exam
  • Medicare covered frames and lenses or contacts
  • Routine eye exam
  • Frames and lenses, or contacts

$0 Copay for a Medicare-covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening)

$0 Copay for (1) pair of Medicare covered eyewear (eyeglasses or contact lenses) after a cataract surgery

$0 Copay for (1) routine eye exam, refraction up to (1) per year

$335 Allowance for frames and lenses and upgrades every year

$0 Copay for a Medicare-covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening)

$0 Copay for (1) pair of Medicare covered eyewear (eyeglasses or contact lenses) after a cataract surgery

$0 Copay for (1) routine eye exam, refraction up to (1) per year

$500 Allowance for frames and lenses and upgrades every year

$0 Copay for a Medicare-covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening)

$0 Copay for (1) pair of Medicare covered eyewear (eyeglasses or contact lenses) after a cataract surgery

$0 Copay for (1) routine eye exam, refraction up to (1) per year

$335 Allowance for frames and lenses and upgrades every year

Mental Health Inpatient

$100 Copay for days 1-10

$0 Copay for days 11-60

$329 Copay for days 61-90

Services may require authorization and a referral.

20% of the Cost of Part B provider services

$1,600* deductible per benefit period

$0* for days 1 through 60

$400* copay per day for days 61 through 90

$800* copay per 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 2023 cost- sharing amounts and may change for 2024. Champion Health Plan will provide updated rates as soon as they are released.

Services may require authorization and a referral.

$100 Copay for days 1-10

$0 Copay for days 11-60

$329 Copay for days 61-90

Services may require authorization and a referral.

Mental Health Outpatient

(Medicare-covered individual and group sessions)

$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.

Skilled Nursing Facility

$0 Copay for days 1-100

Services may require authorization and a referral.

$0 Copay for days 1-100

Services may require authorization and a referral.

$0 Copay for days 1-20

$196 Copay per day for days 21-100

Services may require authorization and a referral.

Outpatient Rehabilitation

Physical Therapy

Speech Therapy

Occupational Therapy

$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.

Ambulance Services

0% or 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.

20% of the Cost

Authorization may be required for non- emergency services.

0% or 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

$0 Copay

100 one-way plan-approved trips

If transportation is not used and you are privately transported to dialysis service, the private driver is reimbursed at 0.60 per mile.

$0 Copay

Unlimited one-way plan-approved trips

If transportation is not used and you are privately transported to dialysis service, the private driver is reimbursed at 0.60 per mile.

$0 Copay

100 one-way plan-approved trips

If transportation is not used and you are privately transported to dialysis service, the private driver is reimbursed at 0.60 per mile.

Medicare Part B Drugs 0% - 20% of the Cost 0% - 20% of the Cost 0% - 20% of the Cost
Dialysis $30 Copay 20% of the Cost $20 Copay
Dialysis Assistance Program

Start Dialysis Treatment
The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify.

Respite Care Support for Home Dialysis

$0 Copay Members receive a visit from a trained caregiver to perform fistula or graft cannulation and machine setup at the beginning of home hemodialysis treatments.

$0 Copay for up to 12 days per year of at-home dialysis administration to replace the primary caregiver assisting in home dialysis treatments.

$0 Copay Members receive a visit from a trained caregiver to perform fistula or graft cannulation and machine setup at the beginning of home hemodialysis treatments.

$0 Copay for up to 12 days per year of at-home dialysis administration to replace the primary caregiver assisting in home dialysis treatments.

$0 Copay Members receive a visit from a trained caregiver to perform fistula or graft cannulation and machine setup at the beginning of home hemodialysis treatments.

$0 Copay for up to 12 days per year of at-home dialysis administration to replace the primary caregiver assisting in home dialysis treatments.

DME

DME, Prosthetics, & Medical Supplies: $0 for items $100 or less

20% of the Cost for items over $100

Services may require authorization.

20% of the Cost

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.

Over-The-Counter Items

$90 Allowance every (3) three months

$0 Copay for weight scale and blood pressure cuff or members with diabetes, ESRD, cardiovascular disorders or chronic heart failure

$200 Allowance every (3) three months

$0 Copay for weight scale and blood pressure cuff or members with diabetes, ESRD, cardiovascular disorders or chronic heart failure

$50 Allowance every (6) six months

$0 Copay for weight scale and blood pressure cuff or members with diabetes, ESRD, cardiovascular disorders or chronic heart failure

Healthy Food Benefit Not Covered

Members participating in the care management program will receive up to $50 per month for produce/groceries.

Services may require authorization.

Members participating in the care management program will receive up to $50 per month for produce/groceries.

Services may require authorization.

Acupuncture and Chiropractic (Medicare-covered services only) $0 Copay $0 Copay $0 Copay
Podiatry Services
(Medicare-covered services only)

$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.

Hospice Covered by Original Medicare Covered by Original Medicare Covered by Original Medicare
Personal Emergency Response System (PERS) $0 Copay $0 Copay $0 Copay
Prescription Drug Coverage
Part D Deductible No Deductible No Deductible $545 deductible (does not apply to Tier 1 and Tier 6) $545 deductible (does not apply to Tier 1 and Tier 6) No Deductible No Deductible
Participating Retail Pharmacy Mail Order Participating Retail Pharmacy Mail Order Participating Retail Pharmacy Mail Order
Initial Coverage Up to a 30-day supply 100-day supply Up to a 30-day supply 100-day supply Up to a 30-day supply 100-day supply
Tier 1: Preferred Generic $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay
Tier 2: Generic $8 Copay $16 Copay 25% of the Cost 25% of the Cost 25% of the Cost 25% of the Cost
Tier 3: Preferred Brand $47 Copay $94 Copay 25% of the Cost 25% of the Cost 25% of the Cost 25% of the Cost
Tier 4: Non-preferred Brand $100 Copay $200 Copay 25% of the Cost 25% of the Cost 25% of the Cost 25% of the Cost
Tier 5: Specialty Tier 33% of the Cost A 100-day supply is not available in Tier 5 25% of the Cost A 100-day supply is not available in Tier 5 25% of the Cost A 100-day supply is not available in Tier 5
Tier 6: Select Care Drugs $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay
During this stage, you pay $0 for drugs in Tier 1 and Tier 6 and 25% of the cost for generic drugs and brand name drugs (plus a portion of the dispensing fee) for drugs in Tier 2, Tier 3, Tier 4, and Tier 5.
Catastrophic Coverage (after you or others on your behalf pay $8,000) During this stage, the plan pays the full cost for your covered Part D drugs.
Important Message About What You Pay for Insulin 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, no matter what cost-sharing tier it’s on. 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, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible. 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, no matter what cost-sharing tier it’s on.
Important Message About What You Pay for Vaccines Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information. 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. Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.
Plan Details
Champion Advantage
Champion Connect
Champion Select
Monthly Premium $0

$20.50

Your cost with Medicare and Medicaid

$0 (with Extra Help)

$13.20
Monthly Premium $0

$21.30

Your cost with Medicare and Medicaid

$0 (with Extra Help)

$16.10
Annual Plan Deductible No deductible No deductible No deductible
Annual Maximum Out of Pocket (MOOP) $499

$9,350

Your cost with Medicare and Medicaid

$0

$499
Inpatient Hospital
In-Network

$0 Copay

Services may require authorization and a referral.

Out-of-Network

Not covered

In-Network

$1,752† deductible per Medicare-covered benefit period

$0 Copay per benefit period

$0 Copay per lifetime reserve days 1-60

Cost-sharing is charged per admission or stay.

If you get authorized inpatient care at an out-of-network hospital after your emergency condition is stabilized, your cost is the cost sharing you would pay at a network hospital.

Services may require authorization and a referral.

Out-of-Network

Not covered

Your cost with Medicare and Medicaid

$0

†if you have full Medicaid benefits, you may pay $0 for your Medicare-covered services

Services may require authorization and a referral

In-Network

$0 Copay

Services may require authorization and a referral.

Out-of-Network

Not covered

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

$125† Copay per Medicare-covered visit

$0 Copay for ASC services

Services may require authorization and a referral.

Out-of-Network

$125† Copay per Medicare-covered visit

$0 Copay for ASC services

Services may require authorization and a referral.

Your cost with Medicare and Medicaid

$0 Copay

†if you have full Medicaid benefits, you may pay $0 for your Medicare-covered services

Services may require authorization and a referral.

In-Network

$140 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

$140 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.

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

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

$0 Copay

20%† Coinsurance for specialist visit in a facility

Authorization may be required for all services except nephrology.

Out-of-Network

$0 Copay

20%† Coinsurance for specialist visit in a facility

Authorization may be required for all services except nephrology.

Your cost with Medicare and Medicaid

$0 Copay

†if you have full Medicaid benefits, you may pay $0 for your Medicare-covered services

Authorization may be required for all services except nephrology.

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.

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

Emergency Care
(Hospital Emergency Department)
Worldwide Emergency Care
In-Network

$140 Copay

Copay is waived if admitted to hospital within 24 hours for related health event

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Urgently Needed Care.

Out-of-Network

$140 Copay

Copay is waived if admitted to hospital within 24 hours for related health event

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Urgently Needed Care.

In-Network

$110† Copay

Copay is waived if admitted to hospital within 24 hours for related health event

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Urgently Needed Care.

Out-of-Network

$110† Copay Copay is waived if admitted to hospital within 24 hours for related health event

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Urgently Needed Care.

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 Medicaid benefits, you may pay $0 for your Medicare-covered services

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Urgently Needed Care.

In-Network

$100 Copay

Copay is waived if admitted to hospital within 24 hours for related health event

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Urgently Needed Care.

Out-of-Network

$100 Copay

Copay is waived if admitted to hospital within 24 hours for related health event

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Urgently Needed Care.

Urgent Care Services
(Non-hospital Urgent Care Center)
Worldwide Urgently Needed Care
In-Network

$0 Copay

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Emergency Care.

Out-of-Network

$0 Copay

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Emergency Care.

In-Network

$0 Copay

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Emergency Care.

Out-of-Network

$0 Copay

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Emergency Care.

Your cost with Medicare and Medicaid

$0 Copay

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Emergency Care.

In-Network

$0 Copay

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Emergency Care.

Out-of-Network

$0 Copay

$0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan. Combined with Worldwide Emergency Care

Diagnostic Services/ Labs/Imaging
  • Diagnostic tests and procedures
  • X-Rays
  • Lab Services
  • Diagnostic radiology services (such as MRI, CT Scans)
  • Therapeutic radiology services (such as radiation treatment for cancer)
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 Medicaid 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.

Hearing Services
  • Medicare-covered services
In-Network

$0 Copay for Medicare-covered services every year

Out-of-Network

$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 every year

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 every year

  • Routine Hearing Exam
  • Fitting/Evaluation for Hearing Aid
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

  • Hearing Aid
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 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

Dental Services
In-Network

$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

Out-of-Network

$0 Copay for Medicare-covered services

20% coinsurance for Preventive Dental Services

30% to 50% 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

$0 for Medicare-covered and Preventive 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

Out-of-Network

$0 for Medicare-covered and Preventive Dental Services

20% of the cost for Preventive Dental Services

30% to 50% 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

Your cost with Medicare and Medicaid

$0 for Medicare-covered and Preventive 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

$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

Out-of-Network

$0 Copay for Medicare-covered dental services

20% coinsurance for Preventive Dental Services

30% to 50% 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

Vision Services
  • Medicare covered eye exam
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

$0 Copay for a Medicare-covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening)

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

$0 Copay for a Medicare-covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening)

Your cost with Medicare and Medicaid

$0 Copay for a Medicare-covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening)

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

$0 Copay for a Medicare-covered exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening)

  • Medicare covered frames and lenses or contacts
In-Network

$0 Copay for (1) pair of Medicare-covered eyewear (eyeglasses or contact lenses) after a cataract surgery

Out-of-Network

Not covered

In-Network

$0 Copay for (1) pair of Medicare covered eyewear (eyeglasses or contact lenses) 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 or contact lenses) after a cataract surgery

In-Network

$0 Copay for (1) pair of Medicare-covered eyewear (eyeglasses or contact lenses) after a cataract surgery

Out-of-Network

Not covered

  • Routine eye exam
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 (1) routine eye exam, refraction up to (1) per year

Out-of-Network

Not covered

Your cost with Medicare and Medicaid

$0 Copay for (1) routine eye exam, refraction up to (1) per year

In-Network

$0 Copay for (1) routine eye exam, refraction up to (1) per year

Out-of-Network

Not covered

  • Frames and lenses, or contacts
In-Network

$335 Allowance for frames and lenses and upgrades every year

Out-of-Network

Not covered

In-Network

$500 Allowance for frames and lenses and upgrades every year

Out-of-Network

Not covered

Your cost with Medicare and Medicaid

$500 Allowance for frames and lenses and upgrades every year

In-Network

$335 Allowance for frames and lenses and upgrades every year

Out-of-Network

Not covered

Mental Health Inpatient
In-Network

$100 Copay for days 1-10

$0 Copay for days 11-60

$329 Copay for days 61-90

Services may require authorization and a referral.

Out-of-Network

Not covered

In-Network

$1,712† deductible per Medicare-covered benefit period

$0 Copay per benefit period

Services may require authorization and a referral.

Out-of-Network

Not covered

Your cost with Medicare and Medicaid

$0 Copay

†If you have full Medicaid benefits, you may pay $0 for your Medicare-covered services

Services may require authorization and a referral.

In-Network

$100 Copay for days 1-10

$0 Copay for days 11-60

$329 Copay for days 61-90

Services may require authorization and a referral.

Out-of-Network

Not covered

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 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.

Skilled Nursing Facility
In-Network

$0 Copay for days 1-20

$214 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

$214† 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 Medicaid benefits, you may pay $0 for your Medicare-covered services

Services may require authorization and a referral.

In-Network

$0 Copay for days 1-20

$196 Copay per day for days 21-100

Services may require authorization and a referral.

Out-of-Network

$0 Copay for days 1-20

$196 Copay per day for days 21-100

Services may require authorization and a referral.

Outpatient Rehabilitation
  • Physical Therapy
  • Speech Therapy
  • Occupational Therapy
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 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.

Ambulance Services
In-Network

0% or 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.

Out-of-Network

0% or 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.

In-Network

$0 Copay for non- emergency ground ambulance transport

20%† of the cost for Medicare-covered ground and air ambulance services

Authorization may be required for non- emergency services.

Out-of-Network

20%† of the cost for non-emergency ground ambulance transport and for Medicare-covered ground and air ambulance services.

Authorization may be required for non- emergency services.

Your cost with Medicare and Medicaid

$0 Copay

†If you have full Medicaid benefits, you may pay $0 for your Medicare-covered services

Authorization may be required for non- emergency services.

In-Network

0% or 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.

Out-of-Network

0% or 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

100 one-way plan-approved trips

If transportation is not used and you are privately transported to dialysis service, the private driver is reimbursed at 0.60 per mile.

Out-of-Network

Not covered

In-Network

$0 Copay

Unlimited one-way plan approved trips

If transportation is not used and you are privately transported to dialysis service, the private driver is reimbursed at 0.60 per mile.

Out-of-Network

Not covered

Your cost with Medicare and Medicaid

$0 Copay

If transportation is not used and you are privately transported to dialysis service, the private driver is reimbursed at 0.60 per mile.

In-Network

$0 Copay

100 one-way plan-approved trips

If transportation is not used and you are privately transported to dialysis service, the private driver is reimbursed at 0.60 per mile.

Out-of-Network

Not covered

Medicare Part B Drugs
In-Network

0% - 20% of the cost

Out-of-Network

0% - 20% of the cost

In-Network

0% - 20%† of the cost

Out-of-Network

0% - 20%† of the cost

Your cost with Medicare and Medicaid

$0 Copay

†If you have full Medicaid benefits, you may pay $0 for your Medicare-covered services

In-Network

0% - 20% of the cost

Out-of-Network

0% - 20% of the cost

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

20%† of the cost

Out-of-Network

20%† of the cost

Your cost with Medicare and Medicaid

$0 Copay

†If you have full Medicaid 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.

Dialysis Assistance Program
  • Venipuncture for Home Dialysis Treatments. The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify.
  • Support for Caregivers
In-Network

$0 Copay members receive a visit from a trained caregiver to perform fistula or graft cannulation and machine setup at the beginning of home hemodialysis treatments

$0 Copay for up to 12 days per year of at-home dialysis treatments or 12, 4-hour respite care periods of coverage per year

Out-of-Network

$0 Copay members receive a visit from a trained caregiver to perform fistula or graft cannulation and machine setup at the beginning of home hemodialysis treatments

$0 Copay for up to 12 days per year of at-home dialysis treatments or 12, 4-hour respite care periods of coverage per year

In-Network

$0 Copay members receive a visit from a trained caregiver to perform fistula or graft cannulation and machine setup at the beginning of home hemodialysis treatments.

$0 Copay for up to 12 days per year of at-home dialysis treatments or 12, 4-hour respite care periods of coverage per year.

Out-of-Network

$0 Copay members receive a visit from a trained caregiver to perform fistula or graft cannulation and machine setup at the beginning of home hemodialysis treatments.

$0 Copay for up to 12 days per year of at-home dialysis treatments or 12, 4-hour respite care periods of coverage per year.

Your cost with Medicare and Medicaid

$0 Copay members receive a visit from a trained caregiver to perform fistula or graft cannulation and machine setup at the beginning of home hemodialysis treatments.

$0 Copay for up to 12 days per year of at-home dialysis treatments or 12, 4-hour respite care periods of coverage per year.

In-Network

$0 Copay Members receive a visit from a trained caregiver to perform fistula or graft cannulation and machine setup at the beginning of home hemodialysis treatments.

$0 Copay for up to 12 days per year of at-home dialysis treatments or 12, 4-hour respite care periods of coverage per year.

Out-of-Network

$0 Copay Members receive a visit from a trained caregiver to perform fistula or graft cannulation and machine setup at the beginning of home hemodialysis treatments.

$0 Copay for up to 12 days per year of at-home dialysis treatments or 12, 4-hour respite care periods of coverage per year.

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

20%† of the cost

Services may require authorization.

Out-of-Network

20%† of the cost

Services may require authorization.

Your cost with Medicare and Medicaid

$0 Copay

†If you have full Medicaid 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.

Over-The-Counter Items and Healthy Foods
In-Network

$300 Allowance every (3) three months

$0 Copay for weight scale and blood pressure cuff for members with diabetes, ESRD, cardiovascular disorders or chronic heart failure

Out-of-Network

Not covered

In-Network

$500 Allowance every (3) three months

$0 Copay for weight scale and blood pressure cuff or members with diabetes, ESRD, cardiovascular disorders or chronic heart failure

Out-of-Network

Not covered

Your cost with Medicare and Medicaid

$500 Allowance every (3) three months

$0 Copay for weight scale and blood pressure cuff or members with diabetes, ESRD, cardiovascular disorders or chronic heart failure

In-Network

$400 Allowance every (3) three months $0 Copay for weight scale and blood pressure cuff or members with diabetes, ESRD, cardiovascular disorders or chronic heart failure

Out-of-Network

Not covered

Acupuncture and Chiropractic (Medicare-covered services only)
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

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

$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 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.

Hospice
In-Network

Covered by Original Medicare

Out-of-Network

Covered by Original Medicare

In-Network

Covered by Original Medicare

Out-of-Network

Covered by Original Medicare

Your cost with Medicare and Medicaid

Covered by Original Medicare

In-Network

Covered by Original Medicare

Out-of-Network

Covered by Original Medicare

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

Fitness
In-Network

$0 Copay

You are reimbursed for up to $35 per month for gym memberships or fitness classes (such as yoga)

Out-of-Network

Not covered

In-Network

$0 Copay

You are reimbursed for up to $35 per month for gym memberships or fitness classes (such as yoga)

Out-of-Network

Not covered

In-Network

$0 Copay

You are reimbursed for up to $35 per month for gym memberships or fitness classes (such as yoga)

Out-of-Network

Not covered

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

Annual Physical Exam
In-Network

$0 Copay for one (1) annual exam

Out-of-Network

Not covered

In-Network

$0 Copay for one (1) annual exam

Out-of-Network

Not covered

In-Network

$0 Copay for one (1) annual exam

Out-of-Network

Not covered

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

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

Prescription Drug Coverage
Part D Deductible
In-Network

No deductible

In-Network

$545 deductible (does not apply to Tier 1 and Tier 6)

Your cost with the Extra Help Program (for low-income subsidy)*

$0 Copay

In-Network

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

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)*

$0 Copay

In-Network

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: 25% of the cost

Mail Order: 25% of the cost

Your cost with the Extra Help Program (for low-income subsidy)*

$0 Copay

In-Network

Participating Retail Pharmacy: 25% of the cost

If you receive assistance under the Extra Help Program*, your cost will be $0 or $1.60 or $4.90 Copay.

Mail Order: 25% of the cost

If you receive assistance under the Extra Help Program*, your cost will be $0 or $1.60 or $4.90 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)*

$0 or $4.80 or $12.15 Copay

In-Network

Participating Retail Pharmacy: 25% of the cost

If you receive assistance under the Extra Help Program*, your cost will be $0 or $4.80 or $12.15 Copay.

Mail Order: 25% of the cost

If you receive assistance under the Extra Help Program*, your cost will be $0 or $4.80 or $12.15 Copay.

Tier 4: Non-preferred Brand
In-Network

Patricipating 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)*

Generics: $0 or $1.60 or $4.90

Copay Brands: $0 or $4.80 or $12.15 Copay

In-Network

Participating Retail Pharmacy: 25% of the cost

If you receive assistance under the Extra Help Program*, your cost will be:

Generics: $0 or $1.60 or $4.90 Copay

Brands: $0 or $4.80 or $12.15 Copay

Mail Order: 25% of the cost

If you receive assistance under the Extra Help Program*, your cost will be:

Generics: $0 or $1.60 or $4.90 Copay

Brands: $0 or $4.80 or $12.15 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 $1.60 or $4.90 Copay

Brands: $0 or $4.80 or $12.15 Copay

Mail Order: A 100-day supply is not available in Tier 5

In-Network

Participating Retail Pharmacy: 25% of the cost

If you receive assistance under the Extra Help Program*, your cost will be:

Generics: $0 or $1.60 or $4.90 Copay

Brands: $0 or $4.80 or $12.15 Copay

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)*

$0 Copay

In-Network

Participating Retail Pharmacy: $0 Copay

Mail Order: $0 Copay

Catastrophic Coverage (after you or others on your behalf pay $2,000)
In-Network

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

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, no matter what cost-sharing tier it's on.

In-Network

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, no matter what cost-sharing tier it's on, even if you haven't paid your deductible.

Your cost with the Extra Help Program (for low-income subsidy)*

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, no matter what cost-sharing tier it's on, even if you haven't paid your deductible.

In-Network

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, no matter what cost-sharing tier it's on.

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 the Extra Help Program (for low-income subsidy)*

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.

*Extra Help Program
In-Network

N/A

Your cost with the Extra Help Program (for low-income subsidy)*

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.

In-Network

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.