Premium

$0 monthly plan premium

Doctor office visits

$0 copay for each Medicare-covered primary care provider visit

Specialist visits

$0 copay for each Medicare-covered specialist visit

No referral required

Preventive and comprehensive dental

There is no cost to you for preventive dental benefits every year, which include the following services:

• One routine visit per year
• Oral exams - One every six months
• Cleaning - One every six months
• Fluoride treatment - One every six months
• Dental X-rays - One dental X-ray visit every five years (frequency varies by service)
• One full mouth radiograph and one panoramic radiograph every five years
• Up to six bitewing or periapical radiographs every year

The combined total comprehensive dental benefits cannot exceed $4,250 every year. The comprehensive dental benefits include the following services up to a $4,250 combined limit every year:

• Minor restorations (fillings)
• Extractions- One per tooth per lifetime
• Dentures- One per arch every five years
• Denture repair and reline - One per year
• Oral surgery
• Periodontics
• Endodontics
• Crowns, one every five years, per tooth. No more than four per calendar year, with no more than two crowns per arch per year.
• Mini-implants (lower arch only) and implant supported denture (lower arch only), one every five years.

Limits:

Prior authorization is required for dentures, periodontics, endodontics, crowns, mini-implants, implant supported dentures, and extractions before services are rendered.

Fixed bridges and all other dental implants, except for mini-implants, are not covered services.

Hearing exams and aids

Diagnostic hearing and balance evaluations performed by your PCP to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider.

• $0 for up to one routine hearing exam every year
• $2,000 allowance for two non-implantable TruHearing Branded Advanced hearing aids every three years (limit 1 hearing aid per ear). After plan-paid benefit, you are responsible for the remaining costs.*
• You must see a TruHearing provider to use this benefit.
• Each TruHearing-branded hearing aid purchase includes one year of follow-up provider visits for fitting and adjustments. These visits are available for 12 months following the purchase of a TruHearing branded hearing aid purchase while the member is enrolled in the plan. 

Hearing aid purchase includes:

• First 12 months of follow-up provider visits
• 60-day trial period
• 3-year extended warranty
• 80 batteries per aid for non-rechargeable models.

Benefit does not include or cover any of following:

• Over the counter (OTC) hearing aids, Ear molds, Hearing aid accessories, Additional provider visits, Additional batteries, batteries when a rechargeable hearing aid is purchased, Hearing aids that are not TruHearing-branded Advanced Aids, Costs associated with loss & damage warranty claims

Cost associated with excluded items are the responsibility of the member and not covered by the plan.

* Remaining costs refers to any amount in excess of your allowance

You must receive your care from a network provider. We will only pay for covered hearing services if you go to an in-network hearing provider. In most cases, you will have to pay for care that you receive from an out-of-network provider.

Vision services

Covered services include:

• $0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye.
• $0 copay for up to one routine vision exam every year.
• Up to $500 every year towards eyeglasses or contact lenses.

Transportation

Twelve one-way trips to plan-approved locations every year (e.g. doctor's office, pharmacy, and hospital). May consist of a car, shuttle, or van service, depending on appropriateness for the situation and the member's needs. Rides must be scheduled at least one business day in advance except in special circumstances. Transportation is authorized for plan-approved locations only (e.g., doctor's office, pharmacy, and hospital).

Limit of 50 miles per one-way trip

Over-the-counter (OTC)

$55 per month to spend on eligible OTC items such as vitamins, pain relievers, cold remedies, and more. Funds are loaded to a planissued debit card each month. 

• Shop through the OTC catalog (PDF) or at participating retail stores 
• No limit on the number of items or orders 
• Unused amounts expire at the end of each month or upon disenrollment from the plan 
• Naloxone is covered as a Part C OTC benefit. The Nicotine Replacement Therapy (NRT) being offered does not duplicate any Part D OTC or formulary drugs.

Home health care

$0 copay for Medicare-covered home health visits.

Prior authorization is required for home health care services.

Outpatient mental health care

$0 copay for each Medicare-covered individual therapy visit.

$0 copay for each Medicare-covered group therapy visit.

Important message about what you pay for vaccines

Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.

Special Supplemental Benefits for the Chronically Ill (SSBCI):

Members who qualify will receive a $65 monthly credit on a plan-issued debit card to help with everyday living expenses. This credit can be used for:

• Healthy foods
• General supports for living (e.g., rent, mortgage, utilities) 
• Pest Control 
• Non-medical transportation

In order to qualify for SSBCI, members must have at least one of the following chronic health conditions: Cardiovascular disorders; chronic and disabling mental health conditions; chronic gastrointestinal disease (limited to end stage liver disease); chronic lung disorders (limited to chronic obstructive pulmonary disorder); congestive heart failure; connective tissue disease; dementia; diabetes mellitus; overweight, obesity, and metabolic syndrome; and Stroke. In addition, the condition must be life threatening or greatly limit overall health or function of the member; the member must be at high risk of hospitalization or other adverse health outcomes; and the member must require intensive care coordination. The plan will review objective criteria to determine a member’s eligibility. For more information or to check eligibility, members should contact the plan.

Unused amounts expire at the end of each month or upon disenrollment from the plan.