Medicare Advantage Prescription Drug HMO Plan

In-Network: $0

In-Network: No Deductible

In-Network: $999

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: $220 Allowance every quarter.
$0 Copay for quarterly allowance to use for healthy foods and produce, over-the-counter items, wellness products 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 a full listing of qualifying conditions.

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.