Plus (PPO)

This plan does not have any medical deductibles.

$0 copay

$40 copay

Not required

$40 copay
The copay is not waived if you are admitted to the hospital.

$0 copay

$250 copay

$110 copay
The copay is waived if you are admitted to the hospital within 24 hours for the same condition.

$110 copayment for Emergency Care and $40 copayment for Urgently Needed Services.

Inpatient care is not covered.

$330/day copay for days 1-6; $0 copay for days 7-90;

Medicare allows 60 “lifetime reserve” days.

20% coinsurance (up to 6 times per year).

Medicare-covered acupuncture: In-network: 20% coinsurance
$200 supplemental benefit for any injury or illness.

Medicare-covered chiropractic care:
In-network: $15 copay
Out-of-network: 30% coinsurance

Routine hearing exam:
In-network: You pay nothing (one routine hearing exam per year from a TruHearing provider.)
Out-of-network: 30% coinsurance

Hearing aids:
In-network & Out-of-network: You pay a $699-$999 copay range depends on the type and style of hearing aids selected for up to two TruHearing-branded hearing aids every year (one per ear per year).

You pay nothing at participating fitness centers.

$590

$0 for a one-month supply
$0 for a two-month supply
$0 for a three-month supply

$15 for a one-month supply
$22.50 for a two-month supply
$30 for a three-month supply

25% ($35 for Select Insulins) for a one-month supply
25% ($70 for Select Insulins) for a two-month supply
25% ($105 for Select Insulins) for a three-month supply

25% ($35 for Select Insulins) for a one-month supply
25% ($70 for Select Insulins) for a two-month supply
25% ($105 for Select Insulins) for a three-month supply

25% of the total cost of a one-month supply (long-term supply is not available)

Available

In-network: $40 copay
Out-of-network: 30% coinsurance

In-network: You pay nothing
Out-of-network: 30% coinsurance

(1 every year)
In-network: You pay nothing
Out-of-network: 45% coinsurance

In-network: You pay nothing
Out-of-network: 30% coinsurance

Our plan pays up to $150 every year for supplemental eyewear from any in-network Superior Vision provider.

In-network: 20% coinsurance
Out-of-network: $100 copay

(2 cleanings per year):

In-network: $0 copay
Out-of-network: 30% coinsurance

Oral exam(s) (Frequency determiend by type of oral exam):
In-network: $0 copay
Out-of-network: 30% coinsurance

Not covered

Not covered

$25 monthly premium (Frequency dependent on procedure)

The plan has a maximum coverage amount of $1,000 per year for in-and out-of-network non-Medicare-covered comprehensive dental services. Members are responsible for the difference between the allowed amount and the billed amount for any out-of-network services.

Frequency dependent on procedure.
In-network & Out-of-network: $50 copay

Frequency dependent on procedure.
In-network & Out-of-network: $100 copay

Frequency dependent on procedure.
In-network & Out-of-network: $50 copay

Frequency dependent on procedure.
In-network & Out-of-network: $100 copay

Frequency dependent on procedure.
In-network & Out-of-network: $50-$100 copay depending on the service