Monthly Premium
You must continue to pay your Medicare Part B premium. If you have a late enrollment penalty, it will still apply.
Part C: $0, Part D: $8.75, TARGETED LIPSA
Max out of pocket
$257 Part B Premium Reduction
$9,250 - $13,900
Deductible
$0
Copays (PCP/Specialist)
$0**
Dental
$0 preventive - 2 cleanings, 2 exams, 2 fluoride treatments & a set of bite-wing x-rays per year. Full mouth x-rays are covered once every 5 years. $0 copay, no deductible, maximum benefit of $2000 per calendar year. Comprehensive dental covered 100%. Implants & dentures are not covered. PPO only network.
Over-the-counter (OTC) benefit
Vision
$0 routine exam. $300 yearly allowance for eyeglasses or contact lenses. 20% discount over $150 base allowance for frames, lenses, lens options. 40% discount applies on the purchase of any additional eyeglasses; must use EyeMed provider.
Hearing / Hearing Aids
$0 routine exam. Copays for hearing aids - 1 per ear/per year; must use NationsHearing.
Inpatient Hospital
You do not pay anything for services listed, as long as you are eligible for cost-sharing assistance under Medicaid.
$2,185 per stay max copay
Preventive Care
No copay for services considered preventive.
Outpatient Diagnostics Labs, Procedures, Tests
You do not pay anything for services listed, as long as you are eligible for cost-sharing assistance under Medicaid.
$0**
Emergency Room / Urgent Care
$115/$40; worldwide coverage
Physical, Occupational and Speech Therapy
You do not pay anything for services listed, as long as you are eligible for cost-sharing assistance under Medicaid.
$0**
Flex Card
$133 per month with rollover for OTC, healthy food/produce, home modifications, pest control, utiliies, fuel at pump, rideshare services & copay assist (excludes vendors & prescription drugs); includes retail over-the-counter
Is Recommended
False
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Plan Documents