Special Needs Plan for Behavioral Health Conditions

In-Network: $7.30

In-Network: No Plan Deductible
$283 Part B Deductible (This 2026 cost sharing amount may change for 2027.)

In-Network: $9,850

In-Network: $0 Copay

In-Network: 20% of the Cost

In-Network: $0 Copay for lab services and X-rays
20% of the Cost for all other services

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

In-Network: 20% of the Cost

In-Network: $0 Copay

In-Network: $115 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: $1,736 deductible per benefit period
$0 for days 1 – 60
$434 Copay per day for days 61 – 90
$868 Copay per day for lifetime reserve days after day 90 of each benefit period (up to 60 days over your lifetime)
100% of all Costs beyond the lifetime reserve days (These 2026 cost sharing amounts may change for 2027.)

In-Network: 20% of the Cost for outpatient hospital services, surgery in an Ambulatory Surgery Center, and outpatient hospital observation

In-Network: $480 Allowance every quarter. Eligible members pay $0 Copay for monthly allowance to use for healthy foods and produce, over-the-counter items, and/or assistance with utilities. Any unused monthly amounts not used within 90 days do not roll over to the next period.
Some of the benefits mentioned are a part of a special supplemental program for the chronically ill. Not all members qualify. Qualifying conditions include bipolar disorder, major depressive disorder, paranoid disorder, schizophrenia, and schizoaffective disorder. Please see your Evidence of Coverage, Chapter 4, Section 2’s Medical Benefit Chart for more information about eligibility.

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
$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 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: $0 Copay

In-Network: $0 Copay

In-Network: 25% of the Cost

In-Network: 25% of the Cost

In-Network: 25% of the Cost

In-Network: 25% of the Cost

In-Network: 25% 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: 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 3 and 4 and no more than $35 for a one-month supply of insulin on Tier 5, even if you haven’t paid your deductible.