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Service area 
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Monthly Plan Premium
You must continue to pay your Medicare Part B premium. If you have a late enrollment penalty, it will still apply. Your Part D prescription drug premium may be reduced or covered if you qualify for Extra Help (Low-Income Subsidy).
Part C: $0*, Part D: $6.30**
Max Out-of-Pocket
$9,850
Deductible
$0
Primary Care Physician/Specialist Copays
$0/$30
Dental
$0 preventive - 2 cleanings, 2 exams, 2 fluoride treatments and 1 set of bitewing X-rays per year. Full mouth X-rays once every 5 years. Comprehensive dental covered 100%. Crowns, implants and dentures are not covered. No deductible and maximum benefit of $2,000 per year. Delta Dental PPO™ network only.
Over-the-Counter Benefit
Helps pay for everyday health items, such as vitamins, toothpaste and pain relievers. Purchase from our online catalog or participating stores using your flex card.
Vision
$0 routine exam. $300 yearly allowance towards the purchase of eyeglasses or contact lenses. 20% discount over the $300 base allowance for frames, lenses and lens options. 40% discount on the purchase of any additional eyeglasses. Must use EyeMed provider.
Hearing and Hearing Aids
$0 routine exam and hearing aid fitting/evaluation. Covers 2 hearing aids per year. $1,000 allowance. Must use NationsHearing provider.
Inpatient Hospital
$395 per day for days 1-5. $0 per day for days 6-90. Unlimited days.
Preventive Care
$0 copay for many preventive health services. These may include checkups, screenings, vaccines and health education. Please see the Evidence of Coverage (EOC) for more information on covered preventive services.
Outpatient Diagnostic Labs, Procedures and Tests
$0 lab tests. $0 - $50 copay depending on service. 
Emergency and Urgent Care
$115 emergency room copay (waived if admitted).  $0-$40 urgent care copay (depending on provider). Worldwide coverage.
Physical, Occupational and Speech Therapy
$15 copay. CMS annual maximum applies.
Prescription Coverage
Yes
Flex Card
$150 per quarter for over-the-counter (OTC) items, healthy food/produce*** and copays for plan-covered services (such as physician services, lab work and physical, occupational and speech therapy; excludes services provided by a vendor and prescription drugs). Unused amounts carry over to the next quarter. Can be used at the register in participating retail stores.
Transportation
36 one-way, non-emergency trips to health-related locations.

Call our licensed Medicare Advantage agents today.

Oct. 1 – March 31, 8 a.m. to 8 p.m., Seven days a week or April 1 – Sept. 30, 8 a.m. to 8 p.m., Monday through Friday

(888) 447-3850 (TTY: 711)
or
Schedule an appointmentScheduleEnroll now

Call our licensed Medicare Advantage agents today.

Oct. 1 – March 31, 8 a.m. to 8 p.m., Seven days a week or April 1 – Sept. 30, 8 a.m. to 8 p.m., Monday through Friday

(888) 447-3850 (TTY: 711)

*You must continue to pay your Medicare Part B premium. If you have a late enrollment penalty, it will still apply.

**Your Part D prescription drug premium may be reduced or covered if you qualify for Extra Help (Low-Income Subsidy).

***This benefit is a special supplemental benefit for the chronically ill (SSBCI) and is made available to members who have been diagnosed with one or more qualifying chronic conditions, are at high risk for hospitalization or other adverse health outcomes and require intensive care coordination. Not all members will qualify for this benefit. Qualifying chronic conditions include but are not limited to diabetes, cardiovascular disorders, chronic lung disorders, cancer, and dementia. For a complete list of qualifying chronic conditions, please see the plan’s Evidence of Coverage (EOC). 

The Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a five-star rating system. Star Ratings are calculated each year and may change.