Out-of- Pocket None 100% after $3,000 for In-Network services per plan year (If you reach this maximum, no further out-of-pocket will be required of you for covered expenses during the year. Expenses for outpatient Part D prescription drugs and plan premiums do not apply toward this maximum) 100% $3,000 for In and Out-of- Network services per plan year (If you reach this maximum, no further will be required of you for covered expenses during the year. Expenses for outpatient Part D prescription drugs, care during foreign travel, and plan premiums do not apply toward this maximum) Physician Services Office visits in conjunction with an illness or injury 80% $147 deductible 100% per visit after $5 copayment to primary care physician; or 100% per after $20 copayment to specialists 100% per visit after $5 copayment to primary care physician; or 100% per visit after $20 copayment to specialists Allergy injections and serum 80% after $147 deductible 100% 100% Diagnostic tests and 80% after $147 deductible 100% 100% lab services 100% 100% 100% Medicare- approved
Services – Abdominal Aortic – Bone Mass once every 24 months (more often if medically 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 amount for the doctor’s 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. 100% for all preventive services covered Original Medicare. Any additional preventive services approved by Medicare mid-year will be covered by Original Medicare. 100% for all preventive services covered Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Plan covers a physical exam annually. 100% for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Plan covers a physical exam annually.
Preventive Services – Breast Cancer Medicare covers screening once every 12 months for all women with 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 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. 100% for all preventive services covered under Original Medicare. Any additional preventive services approved by Medicare mid-year will be covered by Original Medicare. 100% for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Plan covers a physical exam annually. 100% for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Plan covers a physical exam annually.
Preventive Services – Prostate Cancer Screening – Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age 50. – and Tobacco Use Cessation (counseling to stop smoking and tobacco use). Covered if ordered by your doctor. Includes two counseling attempts within a period. Each counseling attempt includes up to four face-to-face visits. – Screening and behavioral counseling interventions in primary care to reduce alcohol misuse – Screening for depression in adults – Screening for sexually transmitted infections (STI) and behavioral counseling to prevent STIs – Intensive behavioral counseling for Cardiovascular Disease – Intensive behavioral therapy for obesity 100% for all preventive services covered under Original Medicare. Any additional preventive services approved by Medicare mid-year will be covered by Original Medicare. 100% for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Plan covers a physical exam annually. 100% for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Plan covers a physical exam annually.
Preventive Services – Welcome to Medicare Visits (initial 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 Preventive Visits or an Annual Wellness Visit. After your first 12 months, you can get one Annual Wellness every 12 months. 100% for all preventive services covered under Original Medicare. Any additional preventive services approved by Medicare mid-year will be covered by Original Medicare. 100% for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Plan covers a physical exam annually. 100% for all preventive services covered Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Plan covers a physical exam annually. Hospital Services Inpatient care at network hospitals (semiprivate room, ancillary services, physician visits) 100% after the following amounts for each benefit period - $1,184 deductible for days 1-60; $296 copayment per day (days 61-90); $592 copayment per lifetime reserve day (days 91- 150) (2) 100% after $200 copayment per day (days 1-5) per admission; 100% after day 5 (1) 100% after $200 copayment per day (days 1-5) per admission; 100% after day 5 (1) Outpatient nonsurgical 80% after $147 90%-100% (based on 90%-100% on services deductible services received) services received) Outpatient surgical 80% after $147 90% 90% services deductible Emergency care 80% $147 100% per visit after 100% per visit after (emergency room, deductible and $65 copayment $65 copayment emergency services) emergency room (waived if admitted (waived if admitted copayment (waived if within 24 within 24 hours) admitted to hospital within 3 days of emergency room visit) Additional Ambulatory surgical 80% $147 90% 90% Medical center deductible Services Immediate care 80% after $147 100% per visit after 100% per after facility deductible $25 copayment $25 copayment