Medicare Advantage Prescription Drug HMO Plan

In-Network: $0

In-Network: No Deductible

In-Network: $499

In-Network: $0 Copay

In-Network: $0 Copay

In-Network: $0 Copay

In-Network: $0 Copay for one exam per year

In-Network: 20% of the Cost

In-Network: $0 Copay

In-Network: $150 Copay
Copay is waived if admitted to hospital within 24 hours for related health event.

In-Network: $0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Urgently Needed Care.

In-Network: $0 Per Stay

In-Network: $100 Copay for outpatient hospital services
$0 Copay for surgery in an Ambulatory Surgery Center
$0 Copay for outpatient hospital observation

In-Network: $225 Allowance every quarter.
$0 Copay for quarterly allowance to use for healthy foods and produce, over-the-counter items, and/or assistance with utilities. Some of the benefits mentioned are a part of a special supplemental program for the chronically ill. Not all members qualify. Qualifying conditions include diabetes, cardiovascular disorders, stroke, overweight, obesity, metabolic syndrome, and cancer. This is not a full listing of eligible conditions. Please see your Evidence of Coverage, Chapter 4, Section 2’s Medical Benefit Chart for Special Supplemental Benefits for the Chronically Ill for more information about eligibility and a full listing of qualifying conditions. Unused monies from the first quarter will roll to the second quarter; but not to subsequent quarters. This rolling schedule for rollover of unused funds applies to the remaining quarters of the year.

In-Network: $0 Copay for 48 one-way trips to plan-approved health-related locations, up to 25 miles per trip

In-Network: $0 Copay for Preventive Dental Services and Medicare-covered dental services
20% to 40% of the Cost for Comprehensive Dental Services. Limitations may apply.
$3,000 yearly benefit coverage limit for preventive and comprehensive dental services combined

In-Network: $0 Copay for one exam and one refraction every year

In-Network: $350 Allowance every year

In-Network: $0 Copay for one exam and one fitting/evaluation every year

In-Network: $149 Copay per TruHearing Advanced hearing aid (all models), up to 2 aids every 3 years

In-Network: $0 Copay for up to 12 four-hour sessions with Helper Bees

In-Network: $0 Copay

In-Network: $0 Copay

In-Network: $0 Copay

In-Network: $5 Copay

In-Network: $10 Copay

In-Network: $47 Copay

In-Network: $94 Copay

In-Network: $100 Copay

In-Network: $200 Copay

In-Network: 33% of the Cost

In-Network: A 100-day supply is not available in Tier 5

In-Network: $0 Copay

In-Network: $0 Copay

In-Network: At retail pharmacy locations, you won’t pay more than $35 for a one-month supply or $105 for a three-month supply of each insulin product covered by our plan on Tiers 2, 3 and 4. You will not pay more than $35 for a one-month supply of insulin on Tier 5. For mail order, you won’t pay more than $70 for a three month supply of each insulin product covered by our plan on Tiers 2, 3 and 4. Long term supplies of insulins in Tier 5 are not available through retail or mail order.