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
$10
Physician Specialist
$30
$30
Urgent Care
$40
$40
Inpatient hospital stay
$120 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
$15 copay
X-Rays
$30 copay
$20 copay
High tech imaging (MRI/CT scan)
$200 copay
$225 copay
Diabetes self-monitoring training and supplies
$0
$0
Hearing services (routine fitting and exam)

$0 copay routine

$0 copay fitting every 3 years

$0 copay routine

$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
$20 copay (in-network) One eye exam every calendar year
Expanded dental benefits
$10 copay (in-network); cleaning and x-rays covered; one cleaning per calendar year. 50% in-network coinsurance for non-routine, restorative, endodontics and extractions services. $2000 annual allowance $10 copay (in-network); cleaning and x-rays covered; one cleaning per calendar year. 50% in-network coinsurance for non-routine, restorative, endodontics and extractions services. $2000 annual allowance
Silver&Fit®Fitness Benefit
$0
$0
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)

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Other Ways to Enroll

Enroll Online

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

Updated October 1, 2018

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