Service area
Monthly Plan Premium
More informationYou must continue to pay your Medicare Part B premium. If you have a late enrollment penalty, it will still apply.$0*
Max Out-of-Pocket
$4,950
Deductible
$0
Primary Care Physician/Specialist Copays
$0/$25
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 50%. Crowns and crown repairs covered 25%. Implants and dentures are not covered. No deductible and maximum benefit of $1,500 per year. Delta Dental PPO™ network only (members who select the optional dental buy-up have access to Delta Dental PPO and Premier networks).
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. $150 yearly allowance towards the purchase of eyeglasses or contact lenses. 20% discount over the $150 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. Copays for hearing aids cover 1 hearing aid per ear per year and 60 batteries per year per hearing aid. Copay will depend upon the technology level of the hearing aid. Must use NationsHearing provider.
Inpatient Hospital
$325 per day for days 1-6. $0 per day for days 7-90. 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 - $150 copay depending on service.
Emergency and Urgent Care
$130 emergency room copay (waived if admitted). $0-$35 urgent care copay (depending on provider). Worldwide coverage.
Physical, Occupational and Speech Therapy
$25 copay. CMS annual maximum applies.
Prescription Coverage
Yes
Flex Card
$30 per quarter for over-the-counter (OTC) items 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 do not carry over. Can be used at the register in participating retail stores.
Transportation
Not covered.
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
Plan Documents (download a PDF)
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.
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.