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Home Medicare Plans Missouri Washington County
Friday, November 22, 2019

HumanaChoice H1716-020 (PPO)
(H1716-020)

by Humana Insurance Company - Washington County, MO
  • This plan does not charge an annual deductible for all drugs. The $320 annual deductible only applies to drugs on certain tiers.
  • The plan offers national in-network prescription coverage. This means that you will pay the same amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
Contact Information

Humana Insurance Company
500 West Main Street
Louisville, KY 40202

Phone: 1-800-457-4708
Toll free: 1-800-457-4708

Website
http://www.humana-medicare.com

Pharmacy
http://www.humana.com/Medicare/medicare_prescription_drugs

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Compare Plan Plan details
Plan Rating3.5 out of 5 stars
Premium and Other Important Information$39 monthly plan premium in addition to your monthly Medicare Part B premium.
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
"Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept ""assignment"" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare ""assignment "" your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare ""limiting charge."" If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare ""limiting charge"" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to ""assignment"" and ""limiting charges"" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.gov/physician or www.medicare.gov/supplier. You can also call 1-800-MEDICARE or ask your physician provider or supplier if they accept assignment."
$5 000 out-of-pocket limit for Medicare-covered services.
$500 annual deductible. Contact the plan for services that apply.
$6 700 out-of-pocket limit for Medicare-covered services.

Doctor and Hospital ChoiceNo referral required for network doctors specialists and hospitals.
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits.
Plan covers you when you travel in the U.S.

Inpatient Hospital CareNo limit to the number of days covered by the plan each hospital stay.
For Medicare-covered hospital stays:
Days 1 - 7: $250 copay per day
Days 8 - 90: $0 copay per day
$0 copay for each additional hospital day.
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
For hospital stays:
Days 1 - 15: $250 copay per day
Days 16 - 90: $0 copay per day

Inpatient Mental Health CareYou get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
For Medicare-covered hospital stays:
Days 1 - 7: $200 copay per day
Days 8 - 90: $0 copay per day
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
For hospital stays:
Days 1 - 15: $250 copay per day
Days 16 - 90: $0 copay per day

Skilled Nursing Facility (SNF)Authorization rules may apply.
Plan covers up to 100 days each benefit period
No prior hospital stay is required.
For SNF stays:
Days 1 - 14: $0 copay per day
Days 15 - 21: $50 copay per day
Days 22 - 100: $125 copay per day
30% of the cost for each SNF stay.

Home Health CareAuthorization rules may apply.
$0 copay for Medicare-covered home health visits
30% of the cost for home health visits

HospiceYou must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice.

Doctor Office Visits$15 copay for each primary care doctor visit for Medicare-covered benefits.
$35 copay for each in-area network urgent care Medicare-covered visit
$35 copay for each specialist visit for Medicare-covered benefits.
30% of the cost for each primary care doctor visit
30% of the cost for each specialist visit

Chiropractic Services$15 copay for each Medicare-covered visit
$15 copay for up to 24 supplemental routine visit(s) every year
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.
30% of the cost for chiropractic benefits.

Podiatry ServicesAuthorization rules may apply.
$35 copay for each Medicare-covered visit
Medicare-covered podiatry benefits are for medically-necessary foot care.
30% of the cost for podiatry benefits.

Outpatient Mental Health CareAuthorization rules may apply.
$35 copay for each Medicare-covered individual therapy visit
$35 copay for each Medicare-covered group therapy visit
$35 copay for each Medicare-covered individual therapy visit with a psychiatrist
$35 copay for each Medicare-covered group therapy visit with a psychiatrist
$35 copay for Medicare-covered partial hospitalization program services
30% of the cost for Mental Health benefits with a psychiatrist
30% of the cost for Mental Health benefits
30% of the cost for partial hospitalization program services

Outpatient Substance Abuse CareAuthorization rules may apply.
$50 copay for Medicare-covered individual visits
$50 copay for Medicare-covered group visits
30% of the cost for outpatient substance abuse benefits.

Outpatient Services/SurgeryAuthorization rules may apply.
$250 copay for each Medicare-covered ambulatory surgical center visit
$0 to $250 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit
30% of the cost for outpatient hospital facility benefits.
30% of the cost for ambulatory surgical center benefits.

Ambulance ServicesAuthorization rules may apply.
$150 copay for Medicare-covered ambulance benefits.
$150 copay for ambulance benefits.

Emergency Care$65 copay for Medicare-covered emergency room visits
Worldwide coverage.
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit.

Urgently Needed Care30% of the cost for Medicare-covered urgently-needed-care visits

Outpatient Rehabilitation ServicesAuthorization rules may apply.
$35 copay for Medicare-covered Occupational Therapy visits
$35 copay for Medicare-covered Physical and/or Speech and Language Therapy visits
30% of the cost for Physical and/or Speech and Language Therapy visits
30% of the cost for Occupational Therapy benefits.

Durable Medical EquipmentAuthorization rules may apply.
20% of the cost for Medicare-covered items
30% of the cost for durable medical equipment

Prosthetic DevicesAuthorization rules may apply.
20% of the cost for Medicare-covered items
30% of the cost for prosthetic devices.

Diabetes Programs and SuppliesAuthorization rules may apply.
$0 copay for Diabetes self-management training
0% to 20% of the cost for Diabetes monitoring supplies
$10 copay for Therapeutic shoes or inserts
30% of the cost for Diabetes self-management training
30% of the cost for Diabetes monitoring supplies
30% of the cost for Therapeutic shoes or inserts

Diagnostic Tests X-Rays Lab Services and Radiology ServicesAuthorization rules may apply.
$0 to $35 copay for Medicare-covered lab services
$0 to $50 copay for Medicare-covered diagnostic procedures and tests
$15 to $35 copay for Medicare-covered X-rays
$15 to $75 copay for Medicare-covered diagnostic radiology services (not including X-rays)
$35 to $50 copay for Medicare-covered therapeutic radiology services
30% of the cost for therapeutic radiology services
30% of the cost for outpatient X-rays
30% of the cost for diagnostic radiology services
30% of the cost for diagnostic procedures tests and lab services

Cardiac and Pulmonary Rehabilitation ServicesAuthorization rules may apply.
$0 to $35 copay for Medicare-covered Cardiac Rehabilitation Services
$0 to $35 copay for Medicare-covered Intensive Cardiac Rehabilitation Services
$35 copay for Medicare-covered Pulmonary Rehabilitation Services
30% of the cost for Cardiac Rehabilitation Services
30% of the cost for Intensive Cardiac Rehabilitation Services
30% of the cost for Pulmonary Rehabilitation Services

Preventive Services and Wellness/Education Programs$0 copay for all preventive services covered under Original Medicare at zero cost sharing:
  • Abdominal Aortic Aneurysm screening
  • Bone Mass Measurement
  • Cardiovascular Screening
  • Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam)
  • Colorectal Cancer Screening
  • Diabetes Screening
  • Influenza Vaccine
  • Hepatitis B Vaccine
  • HIV Screening
  • Breast Cancer Screening (Mammogram)
  • Medical Nutrition Therapy Services
  • Personalized Prevention Plan Services (Annual Wellness Visits)
  • Pneumococcal Vaccine
  • Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only)
  • Smoking Cessation (Counseling to stop smoking)
  • Welcome to Medicare Physical Exam (Initial Preventive Physical Exam)
  • HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details.
    The plan covers the following supplemental education/wellness programs:
  • Written health education materials including Newsletters
  • Additional Smoking Cessation
  • Health Club Membership/Fitness Classes
  • Nursing Hotline
  • 30% of the cost for Medicare-covered preventive services
    50% of the cost for supplemental education/wellness programs

    Kidney Disease and ConditionsAuthorization rules may apply.
    0% to 20% of the cost for renal dialysis
    $0 copay for kidney disease education services
    30% of the cost for kidney disease education services
    0% to 20% of the cost for renal dialysis

    Outpatient Prescription Drugs0% to 20% of the cost for Part B-covered drugs (not including Part B-covered chemotherapy drugs).
    20% of the cost for Part B-covered chemotherapy drugs.
    0% to 30% of the cost for Part B drugs out-of-network.
    This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.humana.com/members/tools/prescription_tools/medicare_drug_list.asp on the web.
    Different out-of-pocket costs may apply for people who
  • have limited incomes
  • live in long term care facilities or
  • have access to Indian/Tribal/Urban (Indian Health Service) providers.
  • The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
    Total yearly drug costs are the total drug costs paid by both you and a Part D plan.
    The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
    Some drugs have quantity limits.
    Your provider must get prior authorization from HumanaChoice H1716-020 (PPO) for certain drugs.
    You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
    If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.
    If you request a formulary exception for a drug and HumanaChoice H1716-020 (PPO) approves the exception you will pay Tier 4: Non-Preferred Brand Drugs cost sharing for that drug.
    $320 deductible on all drugs except Tier 1: Preferred Generic Drugs Tier 2: Non-Preferred Generic Drugs.
    After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 930:
    Tier 1: Preferred Generic Drugs
    Tier 2: Non-Preferred Generic Drugs
    Tier 3: Preferred Brand Drugs
    Tier 4: Non-Preferred Brand Drugs
  • $1 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy
  • $5 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy
  • 20% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy
  • 30% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy
  • $3 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy
  • $15 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy
  • 20% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy
  • 30% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy
  • $10 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy
  • $12 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy
  • 35% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy
  • 40% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy
  • $30 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy
  • $36 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy
  • 35% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy
  • 40% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy
  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Tier 1: Preferred Generic Drugs
    Tier 2: Non-Preferred Generic Drugs
    Tier 3: Preferred Brand Drugs
    Tier 4: Non-Preferred Brand Drugs
  • $10 copay for a one-month (34-day) supply of drugs in this tier
  • $12 copay for a one-month (34-day) supply of drugs in this tier
  • 35% coinsurance for a one-month (34-day) supply of drugs in this tier
  • 40% coinsurance for a one-month (34-day) supply of drugs in this tier
  • Tier 1: Preferred Generic Drugs
    Tier 2: Non-Preferred Generic Drugs
    Tier 3: Preferred Brand Drugs
    Tier 4: Non-Preferred Brand Drugs
  • $0 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $0 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 20% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 30% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 20% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 30% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $10 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $12 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 35% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 40% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $30 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $36 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 35% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 40% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    The plan covers few formulary generics (less than 10% of formulary generic drugs) few formulary brands (less than 10% of formulary brand drugs) through the coverage gap.
    You pay the following:
    Tier 1: Preferred Generic Drugs
    Tier 2: Non-Preferred Generic Drugs
    Tier 3: Preferred Brand Drugs
    Tier 4: Non-Preferred Brand Drugs
  • $1 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred pharmacy
  • $5 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred pharmacy
  • 20% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a preferred pharmacy
  • 30% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a preferred pharmacy
  • $3 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred pharmacy
  • $15 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred pharmacy
  • 20% coinsurance for a three-month (90-day) supply of select drugs covered in this tier from a preferred pharmacy
  • 30% coinsurance for a three-month (90-day) supply of select drugs covered in this tier from a preferred pharmacy
  • $10 copay for a one-month (30-day) supply of select drugs covered in this tier at a non-preferred pharmacy
  • $12 copay for a one-month (30-day) supply of select drugs covered in this tier at a non-preferred pharmacy
  • 35% coinsurance for a one-month (30-day) supply of select drugs covered in this tier at a non-preferred pharmacy
  • 40% coinsurance for a one-month (30-day) supply of select drugs covered in this tier at a non-preferred pharmacy
  • $30 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred pharmacy
  • $36 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred pharmacy
  • 35% coinsurance for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred pharmacy
  • 40% coinsurance for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred pharmacy
  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Tier 1: Preferred Generic Drugs
    Tier 2: Non-Preferred Generic Drugs
    Tier 3: Preferred Brand Drugs
    Tier 4: Non-Preferred Brand Drugs
  • $10 copay for a one-month (34-day) supply of select drugs covered in this tier
  • $12 copay for a one-month (34-day) supply of select drugs covered in this tier
  • 35% coinsurance for a one-month (34-day) supply of select drugs covered in this tier
  • 40% coinsurance for a one-month (34-day) supply of select drugs covered in this tier
  • Tier 1: Preferred Generic Drugs
    Tier 2: Non-Preferred Generic Drugs
    Tier 3: Preferred Brand Drugs
    Tier 4: Non-Preferred Brand Drugs
  • $0 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $0 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • 20% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • 30% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $0 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $0 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • 20% coinsurance for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • 30% coinsurance for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $10 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $12 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • 35% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • 40% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $30 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $36 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • 35% coinsurance for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • 40% coinsurance for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    After your total yearly drug costs reach $2 930 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 86% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 700.
    Please contact the plan for a complete list of drugs covered through the gap.
    After your yearly out-of-pocket drug costs reach $4 700 you pay the greater of:
  • 5% coinsurance or
  • $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs.
  • Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from HumanaChoice H1716-020 (PPO).
    After you pay your yearly deductible you will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until your total yearly drug costs reach $2 930:
    Tier 1: Preferred Generic Drugs
    Tier 2: Non-Preferred Generic Drugs
    Tier 3: Preferred Brand Drugs
    Tier 4: Non-Preferred Brand Drugs
  • $10 copay for a one-month (30-day) supply of drugs in this tier
  • $12 copay for a one-month (30-day) supply of drugs in this tier
  • 35% coinsurance for a one-month (30-day) supply of drugs in this tier
  • 40% coinsurance for a one-month (30-day) supply of drugs in this tier
  • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    You will be reimbursed for these drugs purchased out-of-network up to the plan's cost of the drug minus the following:
    Tier 1: Preferred Generic Drugs
    Tier 2: Non-Preferred Generic Drugs
    Tier 3: Preferred Brand Drugs
    Tier 4: Non-Preferred Brand Drugs
  • $10 copay for a one-month (30-day) supply of select drugs covered in this tier
  • $12 copay for a one-month (30-day) supply of select drugs covered in this tier
  • 35% coinsurance for a one-month (30-day) supply of select drugs covered in this tier
  • 40% coinsurance for a one-month (30-day) supply of select drugs covered in this tier
  • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share which is the greater of:
  • 5% coinsurance or
  • $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs.
  • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

    Dental ServicesAuthorization rules may apply.
    "In general preventive dental benefits (such as cleaning) not covered. However this plan covers preventive dental benefits for an extra cost (see ""Optional Benefits."")"
    $35 copay for Medicare-covered dental benefits
    30% of the cost for comprehensive dental benefits

    Hearing ServicesAuthorization rules may apply.
    In general supplemental routine hearing exams and hearing aids not covered.
  • $35 copay for Medicare-covered diagnostic hearing exams
  • 30% of the cost for hearing exams.

    Vision ServicesAuthorization rules may apply.
    $0 copay for
  • one pair of eyeglasses or contact lenses after cataract surgery
  • $0 to $35 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $0 copay for up to 1 supplemental routine eye exam(s) every year
  • 30% of the cost for eye exams.
    $0 copay for eye exams.
    $0 copay for eye wear.

    Over-the-Counter ItemsPlease visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.

    TransportationThis plan does not cover supplemental routine transportation.

    AcupunctureThis plan does not cover Acupuncture.

    Premium and Other Important InformationPackage: 1 - MyOption Dental High PPO:
    Package: 2 - MyOption Dental Low PPO:
    Package: 3 - MyOption Vision:
    Package: 4 - MyOption Plus:
    $14 monthly premium in addition to your $39 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
  • Preventive Dental
  • Comprehensive Dental
  • $15 monthly premium in addition to your $39 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
  • Eye Exams
  • Eye Wear
  • $21 monthly premium in addition to your $39 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
  • Preventive Dental
  • Comprehensive Dental
  • $25 monthly premium in addition to your $39 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
  • Preventive Dental
  • Comprehensive Dental
  • Eye Exams
  • Eye Wear
  • $1 000 plan coverage limit every year for these benefits.
    $1 500 plan coverage limit every year for these benefits.
    $290 plan coverage limit every year for these benefits.

    Dental Services$0 copay for the following preventive dental benefits:
  • up to 2 oral exam(s) every year
  • up to 2 cleaning(s) every year
  • up to 1 dental x-ray(s) every year
  • 30% of the cost for preventive dental services
    55% of the cost for comprehensive dental services
    55% to 75% of the cost for comprehensive dental services
    $1 000 plan coverage limit for comprehensive dental benefits every year. This limit applies to both in-network and out-of-network benefits.
    $1 500 plan coverage limit for comprehensive dental benefits every year. This limit applies to both in-network and out-of-network benefits.
    Contact the plan for availability of additional in-network and out-of-network comprehensive dental benefits.
    $1 000 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits.
    $1 500 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits.

    Vision Services
  • $0 copay for up to 1 pair(s) of contacts every year
  • $0 copay for up to 1 pair(s) of lenses every year
  • $0 copay for up to 1 pair(s) of glasses every year
  • $0 copay for up to 1 frame(s) every year
  • $0 copay for
  • up to 1 pair(s) of glasses every year
  • up to 1 pair(s) of contacts every year
  • up to 1 pair(s) of lenses every year
  • up to 1 frame(s) every year
  • $0 copay for up to 1 supplemental routine eye exam(s) every year

  • Premium and Other Important InformationIn 2012 the monthly Part B Standard Premium is $99.90 and the annual Part B deductible amount is $140.
    If a doctor or supplier does not accept assignment their costs are often higher which means you pay more.
    Most people will pay the standard monthly Part B premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

    Doctor and Hospital ChoiceYou may go to any doctor specialist or hospital that accepts Medicare.

    Inpatient Hospital CareIn 2012 the amounts for each benefit period are:
    Days 1 - 60: $1 156 deductible
    Days 61 - 90: $289 per day
    Days 91 - 150: $578 per lifetime reserve day
    Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days.
    Lifetime reserve days can only be used once.
    "A ""benefit period"" starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have."

    Inpatient Mental Health CareIn 2012 the amounts for each benefit period are:
    Days 1 - 60: $1 156 deductible
    Days 61 - 90: $289 per day
    Days 91 - 150: $578 per lifetime reserve day
    You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

    Skilled Nursing Facility (SNF)In 2012 the amounts for each benefit period after at least a 3-day covered hospital stay are:
    Days 1 - 20: $0 per day
    Days 21 - 100: $144.50 per day
    100 days for each benefit period.
    "A ""benefit period"" starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have."

    Home Health Care$0 copay.

    HospiceYou pay part of the cost for outpatient drugs and inpatient respite care.
    You must get care from a Medicare-certified hospice.

    Doctor Office Visits20% coinsurance

    Chiropractic ServicesSupplemental routine care not covered
    20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

    Podiatry ServicesSupplemental routine care not covered.
    20% coinsurance for medically necessary foot care including care for medical conditions affecting the lower limbs.

    Outpatient Mental Health Care40% coinsurance for most outpatient mental health services
    Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible.
    """Partial hospitalization program"" is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization."

    Outpatient Substance Abuse Care20% coinsurance

    Outpatient Services/Surgery20% coinsurance for the doctor's services
    Specified copayment for outpatient hospital facility services Copay cannot exceed the Part A inpatient hospital deductible.
    20% coinsurance for ambulatory surgical center facility services

    Ambulance Services20% coinsurance

    Emergency Care20% coinsurance for the doctor's services
    Specified copayment for outpatient hospital facility emergency services.
    Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital.
    You don't have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit.
    Not covered outside the U.S. except under limited circumstances.

    Urgently Needed Care20% coinsurance or a set copay
    NOT covered outside the U.S. except under limited circumstances.

    Outpatient Rehabilitation Services20% coinsurance

    Durable Medical Equipment20% coinsurance

    Prosthetic Devices20% coinsurance

    Diabetes Programs and Supplies20% coinsurance for diabetes self-management training
    20% coinsurance for diabetes supplies
    20% coinsurance for diabetic therapeutic shoes or inserts

    Diagnostic Tests X-Rays Lab Services and Radiology Services20% coinsurance for diagnostic tests and x-rays
    $0 copay for Medicare-covered lab services
    Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests like checking your cholesterol.

    Cardiac and Pulmonary Rehabilitation Services20% coinsurance Cardiac Rehabilitation services 20% coinsurance for Pulmonary Rehabilitation services 20% coinsurance for Intensive Cardiac Rehabilitation services
    This applies to program services provided in a doctor+s office. Specified cost sharing for program services provided by hospital outpatient departments.

    Preventive Services and Wellness/Education ProgramsNo coinsurance copayment or deductible for the following:
  • Abdominal Aortic Aneurysm Screening
  • Bone Mass Measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions.
  • Cardiovascular Screening
  • Cervical and Vaginal Cancer Screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk.
  • Colorectal Cancer Screening
  • Diabetes Screening
  • Influenza Vaccine
  • Hepatitis B Vaccine for people with Medicare who are at risk
  • HIV Screening. $0 copay for the HIV screening but you generally pay 20% of the Medicare-approved amount for the doctor+s visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.
  • Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35-39.
  • Medical Nutrition Therapy Services Nutrition therapy is for people who have diabetes or kidney disease (but aren+t on dialysis or haven+t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease
  • Personalized Prevention Plan Services (Annual Wellness Visits)
  • Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information.
  • Prostate Cancer Screening + Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age 50.
  • Smoking Cessation (counseling to stop smoking). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits.
  • Welcome to Medicare Physical Exam (initial preventive physical exam) When you join Medicare Part B then you are eligible as follows. During the first 12 months of your new Part B coverage you can get either a Welcome to Medicare Physical Exam or an Annual Wellness Visit. After your first 12 months you can get one Annual Wellness Visit every 12 months.

  • Kidney Disease and Conditions20% coinsurance for renal dialysis
    20% coinsurance for kidney disease education services

    Outpatient Prescription DrugsMost drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan or you can get all your Medicare coverage including prescription drug coverage by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage.

    Dental ServicesPreventive dental services (such as cleaning) not covered.

    Hearing ServicesSupplemental routine hearing exams and hearing aids not covered.
    20% coinsurance for diagnostic hearing exams.

    Vision Services20% coinsurance for diagnosis and treatment of diseases and conditions of the eye.
    Supplemental routine eye exams and glasses not covered.
    Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery.
    Annual glaucoma screenings covered for people at risk.

    Over-the-Counter ItemsNot covered.

    TransportationNot covered.

    AcupunctureNot covered.

    Point of ServiceYou may go to any doctor specialist or hospital that accepts Medicare.
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    Help is available. If you have limited income and resources, you may qualify for help paying your Medicare health care and/or prescription drug coverage costs. For more information, visit socialsecurity.gov, call Social Security at 1-800-772-1213, or apply for help at your State Medical Assistance (Medicaid) office.

    If you have questions about Medicare, visit medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.