Chronic Condition


Heart and Diabetes Care
Lung Care

Enroll Online
Enroll Online
Monthly premium
$25
$33
In-network deductible
$0
$0
Primary Care Physician office visits
$10 copay
$10 copay
Physician Specialist
$30 copay
$30 copay 
Urgent Care
$40 copay
$40 copay
Inpatient hospital stay
$125 per day for days 1-8
$170 per day for days 1-8
Outpatient surgery $300 copay
$225 copay
Ambulatory Surgical Center
$200 copay
$125 copay
Emergency Care
$120 copay
$120 copay
Lab services
$10 copay
$10 copay
X-Rays
$30 copay
$20 copay
High tech imaging (MRI/CT scan)
$200 copay
$225 copay
Diabetes self-monitoring training and supplies
$0 copay
$0 copay
Hearing services (routine fitting and exam)

$0 copay routine exam

$0 copay fitting every 3 years

$0 copay routine exam

$0 copay fitting every 3 years

Hearing aids
$800 allowance every 3 years
$800 allowance every 3 years
Routine vision (one annual eye exam)
$20 copay (in-network) One eye exam every calendar year

$125 allowance toward eyeglass frames or contact lenses every 2 years

$20 copay (in-network) One eye exam every calendar year

$125 allowance toward eyeglass frames or contact lenses every 2 years
Expanded dental benefits
$10 copay (in-network); cleanings and x-rays covered; two routine visits per calendar year. 50% in-network coinsurance for non-routine, restorative, endodontics and extractions services. $2000 annual allowance $10 copay (in-network); cleanings and x-rays covered; two routine visits per calendar year. 50% in-network coinsurance for non-routine, restorative, endodontics and extractions services. $2000 annual allowance
SilverSneakers® Fitness Benefit
$0 copay $0 copay
Prescription Drug Benefits $0 deductible $0 deductible
Tier 1 Preferred Generics $0/$8 $0/$10
Tier 2 Generic Drugs $5/$15 $5/$20
Tier 3 Preferred Brand $40/$47 $40/$47
Tier 4 Nonpreferred Drugs $93/$100 $93/$100
Tier 5 Specialty Drugs 33 percent
(30 day supply)
33 percent
(30 day supply)
Tier 6 Select Care $0/$7 $0/$7
After initial coverage limit reached 25 percent generic;
25 percent brand
25 percent generic;
25 percent brand
Part D Excluded Drugs Not covered Not covered
Over-the-counter drugs (OTC)
$15 monthly allowance (cannot be carried over from month to month)
$15 monthly allowance (cannot be carried over from month to month)
Transportation Benefit
24 plan approved round trips
24 plan approved round trips
Meals Benefit – Post Hospital Discharge
2 meals per day for 14 days
2 meals per day for 14 days
Landmark Health
$0 copay
$0 copay
Medical Nutritional Therapy
$0 copay
$0 copay
Nutritional/Dietary Benefit
$0 copay
$0 copay
Virtual Care
$0 copay
$0 copay
Health Coaching and Education Benefit
$0 copay
$0 copay

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Other Ways to Enroll

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Other Ways to Enroll

 

You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

Plan Info

Evidence of Coverage

Summary of Benefits

Annual Notice of Changes - Heart and Diabetes Care

Annual Notice of Changes - Lung Care

Out of Network Coverage Rules

Web Content Viewer - Fixed Context

Updated February 10, 2020

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