No co-payments for Medicare-covered medical services, covers:

• Doctor office visits (includes specialists)
• Outpatient care (includes rehabilitation, surgery, substance abuse and mental health care)
• Home health care
• Inpatient care at a hospital or skilled nursing facility
• Diabetes self-monitoring training and supplies
• Health screenings
• Vaccines

For Medicare-covered medical services:

• No co-payments for primary care doctor visits, home health care, diabetes self-monitoring training, health screenings and vaccines
• Low co-payment for specialist doctor visits, outpatient care (includes rehabilitation, substance abuse and mental health care); inpatient hospital care (includes mental health, substance abuse and rehabilitation services)

No co-payments for Medicare-covered medical services, covers:

• Doctor office visits (includes specialists)
• Outpatient care (includes rehabilitation, surgery, substance abuse and mental health care)
• Home health care
• Inpatient care at a hospital or skilled nursing facility
• Diabetes self-monitoring training and supplies
• Health screenings
• Vaccines

For Part D covered drugs, please refer to our formulary.

$0 to $2.50 co-payment or 15% coinsurance for generic drugs

$0 to $6.30 co-payment or 15% coinsurance for brand, preferred and specialty drugs

$5.00 co-payment for generic drugs

$30 to $60 co-payment for brand, preferred and specialty drugs

$0 to $1.10 co-payment for generic drugs

$0 to $3.30 co-payment for brand, preferred and specialty drugs

No co-payment for annual physicals.

No co-payment for:

• One routine eye exam every year
• One pair of glasses or contact lenses every year ($120 frame allowance, plus the cost of standard lenses)

No co-payment for:

• One routine eye exam every year
• One pair of glasses or contact lenses every year ($100 limit for eyewear every year)

Not covered

Covers additional dental services (not covered by Medicaid, up to $3,000 per year), includes:

• One cleaning every three months,
• Preventive and restorative services, including periodontic and endodontic services and extractions

Covers additional dental services (up to $1,000 per year) includes:

• One oral exam every year,
• One cleaning every six months,
• One dental x-ray every year,
• Basic restorative services such as fillings, extractions, or dentures

Covers preventive and basic restorative dental services.

• Nursing hotline
• Smoking cessation counseling

• Nursing hotline
• Smoking cessation counseling
• Health club membership and fitness classes at a participating facility

• Nursing hotline
• Smoking cessation counseling

• Care management and coordination of medical care and long term care services
• Nursing hotline
• Smoking cessation counseling

Not covered

Four round-trips every three months to and from plan-approved locations

Not covered

All scheduled transportation to and from medical and health related appointment. (Coverage includes ambulette, care service and public transportation.)

Not covered

Not covered

Not covered

All medically necessary long term care provided in home and/or community-based organizations, including:

• Personal care services
• Medical social services
• Home delivered meals
• Adult day health care and social day services
• Personal Emergency Response System (PERS)
• Private duty nursing

Up to $1,200 in benefits for medically necessary care when you travel outside the United States.

Not covered