2026 Access (PPO) Plan

$550 (Tiers 3-5)

Catastrophic Coverage: Once you've spent $2,100 in out-of-pocket prescription costs you are in the Catastrophic Coverage Stage. If you reach the Catastrophic Coverage Stage, you pay nothing for covered Part D drugs and for excluded drugs that are covered under our enhanced benefit.

$0 for 30-day retail supply

Part B: $35/month (Other Part B Drugs: Up to 20% coinsurance in-network; 40% coinsurance out-of-network*). Prior Authorization may be required in-network.

Part D: Your copay for covered insulin will not exceed $35 or 25% of the total cost per 30-day supply regardless of the drug tier. This means that your copay is the Tier 1, Tier 2, Tier 3, or Tier 4 copay, or $35 per 30-day supply, whichever is lower. Your actual copay may be lower depending on the drug tier and total cost of the insulin drug. Please refer to your Evidence of Coverage for more details.

$250 for services marked with an (*). Please refer to your Evidence of Coverage for a complete list of in-network and out-of-network services to which the deductible applies.

$8,500 for in-network costs; $10,100 for a combination of in and out-of-network costs

In-Network: $0; Out-of-Network: $80 per visit*

In-Network: Includes Medicare covered services and additional telehealth services. $0 copay for e-visits, virtual visits, and remote patient monitoring with your PCP or Specialist. For all other telehealth visits, copay and other requirements are the same as the corresponding in-person visit copay.

Out-of-Network: Includes Medicare covered services; cost share is the same as the corresponding in-person visit. Additional telehealth services not covered. 

In-Network: $0. Prior Authorization may be required for in-network services; Out-of-Network: 40% coinsurance*

In-Network: $0 per annual visit; Out-of-Network $65 per annual visit

In-Network: $0 per annual visit; Out-of-Network: $65 per annual visit.

In-Network: $55 per visit; Out-of-Network: $80 per visit*

In-Network: $10 per day. Prior Authorization may be required for in-network services; Out-of-Network: 40% coinsurance*

In-Network: $40 per day. Prior Authorization may be required for in-network services; Out-of-Network: 40% coinsurance*

In-Network: Ultrasound: $60 per day; Others: $225 per day; Prior Authorization may be required for in-network services; Out-of-Network: 40% coinsurance*

In-Network: Colonoscopy: $0; Others (Ambulatory Surgical Center, ASC): $295 per day*; Others (Non-ASC): $435 per day*; Prior Authorization may be required for in-network services 

Out-of-Network:50% coinsurance*

In-Network: $30 per visit; Out-of-Network: 40% coinsurance*. Prior authorization may be required for in-network services.

In-Network: $435 per stay*; Out-of-Network: 50% of cost*. Copay is waived if admitted inpatient within 1 day for the same condition. Prior authorization may be required. Prior authorization may be required for in-network services.

In-Network: $0; Out-of-Network: 40% coinsurance*

In-Network: $0; Out-of-Network: 40% coinsurance* (deductible does not apply to prostate specific antigen test and colorectal cancer screening other than barium enemas).

In-Network: $0; Out-of-Network: 40% coinsurance*

$40 per visit for urgently needed services provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgent care copayment is NOT waived if admitted inpatient within 1 day.

$115 per visit. Copay is waived if admitted to observation or inpatient within 1 day for the same condition, and applicable observation or inpatient copay will apply.

In-Network: $485* per day for days 1-5; $0 after day 5; Prior Authorization may be required for in-network services; Out-of-Network: 40% coinsurance*

In-Network and Out-of-Network*: $325 per one-way trip. Coverage for medically necessary Ambulance Services. Prior authorization may be required for non-emergency transportation. Includes worldwide emergency transportation coverage.

In-Network: $20 per visit
Out-of-Network: $65 per visit* 

Covers up to 12 visits in 90 days for members with chronic lower back pain. 8 additional visits covered for those demonstrating an improvement. No more than 20 visits administered annually.

Not covered.

Not covered.

You receive a SilverSneakers fitness membership at no additional cost giving you access to 15,000+ gyms nationwide, trained instructors, classes and health and nutrition tips with exercise videos. SilverSneakers includes a fitness membership with access to all basic amenities plus group exercise classes designed to improve muscular strength and endurance, mobility, flexibility, range of motion, balance, agility and coordination. At-home exercise kits are available for SilverSneakers members, including those who have a disability, are recovering from a medical procedure or illness, live in a rural area or experience traffic difficulties and can’t make it to a fitness center. See your Evidence of Coverage for more information. 

You are eligible for up to 2 covered hearing aids per year, 1 aid per ear. To be covered, the hearing aids must be on the TruHearing, Inc. formulary and must be purchased through TruHearing, Inc. Different copays apply.

$250 Standard Level

$475 Superior Level

$650 Advanced Level

$850 Advanced Plus Level

$1,150 Premier Level

Out-of-Network: Hearing aid must be ordered only through TruHearing, Inc.

$50 per calendar quarter to spend on Medicare approved health-related OTC items. Members receive quarterly credit on the Visa Flex Advantage spending card to use towards covered OTC items at participating retailers and plan approved online stores. Unused quarterly balances do not rollover. You may also purchase OTC hearing aids using your OTC benefits. See Evidence of Coverage (EOC) for more information.

$250 allowance per calendar year for standard eyeglasses (prescription lenses, frames, or a combination of lenses and frames) and/or contact lenses purchased from any provider. The annual allowance may be used to purchase upgrades for Medicare-covered and/or therapeutic eyewear as well as routine/corrective eyewear. Note: Only one purchase is allowed per calendar year up to the benefit amount; any unused amount after the single purchase will expire and cannot be applied toward another purchase during the calendar year.