Premium

$0 monthly plan premium

Doctor office visits

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

Specialist visits

20% coinsurance 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:

• 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 $1,250 every year. The comprehensive dental benefits include the following services up to a $1,250 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:

All comprehensive dental services require prior authorization.

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

Hearing

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

Hearing aid benefit includes:

• $0 copay for Select-level technologies every 3 years
• up to two [2] hearings aids (1 aid per ear) every 3 years for Select hearing aid technology levels through NationsHearing

All hearing aids offered through NationsHearing include:

• 60-day evaluation period with a 100% money-back guarantee (no restocking fees)
• 1 Hearing aid fitting per hearing aid
• 3 follow-up appointments within one year of the fitting date
• 3-year supply of batteries (for nonrechargeable hearing aids, up to 60 cells per ear, per year)
• 3-year comprehensive manufacturer's warranty, including one time replacement for lost or damaged hearing aids
• Earmold(s) (first set, when needed)
• Unlimited ongoing member support via NationsHearing

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 $100 every year toward eyeglasses or contact lenses

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

Special Supplemental Benefits for the Chronically Ill (SSBCI)

Members who qualify for SSBCI may use their $58 per month OTC allowance to help with everyday living expenses. This benefit can be used for

• Over-the-Counter eligible items
• Healthy foods
• General supports for living (e.g., rent, mortgage, utilities)

The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify. Only Special Supplemental Benefits for the Chronically Ill (SSBCI) eligible members may use their allowance towards rent, utilities, internet, [and] healthy foods[,] [pest control,] [and] [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), Congestive heart failure, Chronic lung disorders (limited to chronic obstructive pulmonary disease), Connective Tissue Disease, Dementia, Diabetes mellitus, Stroke, and/or Overweight, obesity, and metabolic syndrome.

In addition, member must satisfy at least one of the following: Had one or more inpatient admissions (inclusive of behavioral health) related to the chronic condition in the last 12 months. Had one or more urgent care or emergency room visits related to the chronic condition in the last 12 months. Had two or more outpatient visits related to the chronic condition (including primary care or specialty care visits) in the last 12 months. Are a patient who requires home health visits related to the chronic condition. Are a patient with one or more chronic conditions and a need for one or more pieces of durable medical equipment (DME) in the outpatient setting, limited to: group 3 power/manual wheelchair, noninvasive ventilation (NIV), bipap machines, mechanical in-exsufflation devices, or group 2 or group 3 mattresses.

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

For more information, please visit the Special Supplemental Benefits for the Chronically Ill (SSBCI) Information page.

Non-emergency transportation trips to your provider.

Twelve (12) 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. Limit of 50 miles per one-way trip

Over-the-counter (OTC)

$58 per month to spend on eligible OTC items such as vitamins, pain relievers, cold remedies, and more. Funds are loaded to a plan-issued debit card each month.

All members may use the OTC allowance towards eligible home and bathroom safety devices such as grab bars or doorknobs, non-slip floor coverings, safety chairs, bathroom modification aids. Members can shop through the OTC catalog or at participating retail stores. Unused amounts expire at the end of each month or upon disenrollment from the plan.

• Members can shop through the OTC catalog (PDF) and OTC catalog - Spanish (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

Outpatient mental health care

$0 copay for each Medicare-covered individual therapy visit

$0 copay for each Medicare-covered group therapy visit

$0 copay for each Medicare-covered individual therapy visit with a psychiatrist

$0 copay for each Medicare-covered group therapy visit with a psychiatrist

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.