Must be enrolled in Medicare and Medicaid to enroll in this plan
$0 or $38 premium
$4,200 on a Flex Card to pay for out-of-pocket costs, including:
$1,500 to pay for prescription hearing aids
$300 to pay for eyewear like eyeglasses and contact lenses from your choice of hundreds of participating providers and retailers
$2,400 ($100 available per month combined for healthy foods and over-the-counter items that you can purchase at major retailers or online and $100 available per month to pay for approved utility services, such as phone, gas, electric, water, internet, cable or satellite television)
Benefit restrictions/maximums apply
Unused funds for healthy food, over-the-counter items and utility services do not roll over to the next coverage period and will expire at the end of each month.
$0 deductible for in-network medical services, if you are eligible for Medicare cost-sharing assistance
$0 copay and no deductible for all covered prescription drugs
See a specialist without a referral
In-Network Medical |
|||
|---|---|---|---|
| HMO-POS D-SNP | |||
| Premium | $0 or $38 Per Month** | ||
| Medical Deductible | $0 or $240 Per Year** (if eligible for Medicare cost-sharing assistance) | ||
| Preventive Care | $0 Copay | ||
| Primary Care Visits | $0 Copay or 20% After Part B Deductible** | ||
| Specialist Visits | $0 Copay or 20% After Part B Deductible** | ||
| Urgent Care | $0 Copay or 20% Coinsurance up to $45** | ||
| Emergency Room Care | $0 Copay or 20% Coinsurance up to $100 (worldwide ER not covered)** | ||
| Inpatient Hospital Care | $0 Per Day or $1,632 deductible for Days 1-60** $0 or $408 per day for days 61-90** $0 or $816 per day for days 91-150** (Per benefit period) | ||
| Outpatient Hospital Surgery | $0 Copay or 20% After Part B Deductible** | ||
| Maximum Out-of-Pocket Limit | $9,350 Per Year | ||
**Member cost-sharing depends on the member’s level of assistance from Medicaid
DUAL PLUS (HMO-POS D-SNP)
|
|||
|---|---|---|---|
| IN-NETWORK BENEFIT | DRUG STAGES | COST SHARE | |
| PRESCRIPTION DRUGS (31-day supply) | Deductible | $0 | |
| Generics | $0 | ||
| Brand | $0 | ||
| Coverage Gap | $0 | ||
Plan Features to Help Keep You Healthy |
|
|---|---|
| Flex Card |
$4,200 on a Flex Card to pay for out-of-pocket costs, including:
|
| Dental Services | Dental benefits including two dental cleanings and two exams per year covered at no cost (total allowance of $4,000 combined preventive and comprehensive dental services). Can use allowance amount toward dentures. |
| Vision Services | No-cost routine eye exam (up to 1 every year) with the freedom to choose from hundreds of participating providers, plus $300 to spend on eyewear via Flex Card |
| Hearing Services | $0 copay for routine hearing exam (up to 1 every year), plus $1,500 to spend on prescription hearing aids via Flex Card |
| Fitness Benefit | No-cost fitness studio/gym membership, plus digital fitness and wellness content |
| Healthy Foods, Over-the-Counter Items and Utilities |
$2,400 ($100 available per month combined for healthy foods and over-the-counter items that you can purchase at major retailers or online and $100 available per month to pay for approved utility services, such as phone, gas, electric, water, internet, cable or satellite television).
|
| Transportation | 84 one-way trips per year |
| Personal Emergency Response System | Covered at no cost with 24/7 service |
* For in-network services only, where applicable. Retailer restrictions may apply.
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