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Premium $0.00 monthly
Benefits
Medical coverage | |
|---|---|
Medical Deductible | $0.00 |
Doctor Office Visits | $0 copay |
Specialist Office Visit | $35 copay |
Telehealth | $0 copay for urgently needed services, primary care provider services, specialist services, and outpatient mental health (mental health specialty and psychiatry - individual and group sessions). |
Inpatient Hospital Care | $375 copay per day for days 1-5. $0 copay per day for days 6-90. |
Comprehensive dental benefits | $3,000 per year for comprehensive (and preventive) dental services. Please see plan documents for more details. |
Comprehensive hearing benefits | $0 copay for 1 routine hearing exam per year. $1,000 allowance per hearing aid (one per year). Please see plan documents for more details. |
Comprehensive vision benefits | $0 copay for 1 routine eye exam per year. $150 per year for routine eyewear (contacts, eyeglasses, and upgrades). Please see plan documents for more details. |
Nations Benefits Card (Over-the-Counter Items) | $25 per quarter, no rollover |
24/7 Nurse Hotline | Access to the Nurse24 nurse advice line 24 hours a day, seven days a week, 365 days a year. Registered nurses can provide information on home treatment of minor illnesses and injuries, how to prepare for doctor visits, how to understand your prescription drugs, and much more.
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SilverSneakers® fitness program | Access to a fitness benefit virtually and at participating SilverSneakers facilities, giving you access to instructor-led group exercise classes, exercise equipment, and options to get active outside of traditional gyms, as well as virtual options. |
In-Network Maximum Out-of-Pocket | $6,500 |
Medical coverage (Out-of-Network) | |
|---|---|
Out-of-Network Coverage | Out-of-network services are not covered, except for emergency and urgently needed care. You must use network providers for plan services, except in emergency situations. |
Pharmacy coverage | |
|---|---|
Prescription deductible | $460 on Tier 3, Tier 4, and Tier 5 |
Out-of-Pocket | $2,100 |
One-Month Supply (Retail Pharmacy) with Standard Cost Sharing | |
Preferred Generic | $0 copay |
Generic | $5 copay |
Preferred Brand | 17% coinsurance |
Non-Preferred Drug | 34% coinsurance |
Specialty Tier | 27% coinsurance |
Insulin Products | Lesser of a $35 copay or 17% coinsurance on Tier 3 and the lesser of a $35 copay or 25% coinsurance on Tier 4 and Tier 5 for a one-month supply |
100-Day Supply (Retail Pharmacy) with Standard Cost Sharing | |
Preferred Generic | $0 copay |
Generic | $12.50 copay |
Preferred Brand | 17% coinsurance |
Non-Preferred Drug | 34% coinsurance |
Specialty Tier | Not covered |
Insulin Products | Lesser of a $35 copay or 17% coinsurance on Tier 3 and the lesser of a $35 copay or 25% coinsurance on Tier 4 and Tier 5 for a one-month supply |
Plan Documents | |
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Summary of Benefits | |
Plan Documents | |
Preferences
Plan: H9699-007
Limitations, copayments, and restrictions may apply. See above or contact the plan for more details.
*Enrollee must continue to pay the Medicare Part B premium.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help,call:- 800-MEDICARE (800-633-4227). TTY users should call 877-486-2048. 24 hours a day, 7 days a week.
- The Social Security Office at 800-772-1213. TTY users should call 1-800-325-0778. Monday through Friday, 7:00 a.m. to 7:00 p.m.
- Your State Medicaid Office.
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