Compare Plans
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Member Services Hours of Operation
April 1 – September 30: Monday – Friday, 8 am – 8 pm
October 1 – March 31: Monday – Sunday, 8 am – 8 pm
Plan Details
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Champion Advantage
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Champion Connect
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Champion Select
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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. |
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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. |
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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. |
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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 |
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Urgent Care Services
(Non-hospital Urgent Care Center) |
$0 Copay | $0 Copay | $0 Copay | |||
Diagnostic Services/ Labs/Imaging
|
$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. |
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Hearing Services
|
$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 |
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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 |
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Vision Services
|
$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 |
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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. |
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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. |
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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. |
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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. |
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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. |
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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. |
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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
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. |
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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. |
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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 |
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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. |
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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. |
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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
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Champion Advantage
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Champion Connect
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Champion Select
|
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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 |
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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. |
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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 |
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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. |
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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 |
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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. |
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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 |
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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 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. |
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Hearing 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 |
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|
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 |
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|
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 |
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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 |
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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
$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) |
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|
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 |
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|
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 |
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|
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 |
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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 |
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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. |
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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. |
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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
$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. |
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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. |
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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 |
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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 |
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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. |
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Dialysis Assistance Program
|
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. |
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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. |
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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 |
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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 |
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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. |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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. |
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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. |