2024 Preferred (HMO) Plan

$0

Gap Coverage: Once you and your plan have spent $5,030 on covered drugs combined, you're in the Coverage Gap Stage where the 30-day supply costs are: $0 for Tier 6 vaccine drugs, $35 for covered insulin drugs, and 25% of the cost for Part D generic and brand name drugs, plus a portion of the dispensing fee for Tiers 1-5.

Catastrophic Coverage: Once you've spent $8,000 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

Initial Coverage Stage

$0 for 30-day retail supply; $0 for 90-day mail order supply

Initial Coverage Stage

$0 for 30 day retail supply; $0 for 90 day mail order supply

Initial Coverage Stage

$47 ($35 for insulin) for 30 day retail supply; $94 ($70 for insulin) for 90 day mail order supply

Initial Coverage Stage

$100 ($35 for insulin) for 30-day retail supply; $200 ($70 for insulin) for 90-day mail order supply

Initial Coverage Stage

33% of cost for 30-day retail supply

$0

$0

$4,900

$0 per visit

$0 copay for e-visits, virtual check-ins, and remote patient monitoring with your PCP or Specialist.

For all other telehealth visits, copay is the same as corresponding in-person visit copay

$0 per day for Lab Services. Prior Authorization may be required.

$15 per annual visit

$0 per annual visit

$45 per visit

$30 per day. Prior Authorization may be required.

$30 per day. Prior Authorization may be required.

Ultrasound: $60 per day; Others: $250 per day. Prior Authorization may be required.

Colonoscopies: $0; Other outpatient surgeries (Ambulatory Surgical Center, ASC): $270 per day; Other outpatient surgeries (Non-ASC): $370 per day. Prior Authorization may be required.

$30 per visit

$0 per annual visit

$0 per annual visit

$0

$45 per visit
 

Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but, given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers.

$90 per visit. There is no limit to the number of visits in a plan year

$395 per day for days 1-5. After day 5 you will pay $0 per day. Prior Authorization may be required.

$300 per one-way trip for medically necessary Ambulance Services. Prior authorization may be required for non-emergency transportation. Includes worldwide emergency transportation coverage.

$0

The plan pays up to the calendar year maximum of $3,000.

$0 copay; Two per year.

$0 copay; Once every 36 months (includes the initial dental history and charting of teeth). 

$0 copay; Two per year (when oral conditions indicate need).

20% coinsurance; Once every 60 months.

20% coinsurance; As needed.

$0 copay; Two per year

50% coinsurance; Once every 6 months following active periodontal therapy, not to be combined with regular cleanings

50% coinsurance; Once per tooth. 

50% coinsurance; Once per tooth.

50% coinsurance; Once every 24 months per bridge or denture.

50% coinsurance; Once per arch within 84 months.

50% coinsurance; Once within 84 months per tooth (when teeth cannot be restored with regular filings due to fracture or decay).

50% coinsurance; Implants are limited to 1 per tooth per 5 years.  Implant coverage is limited to the surgical placement of an endosteal implant (in lieu of a 3-unit bridge), abutment supported porcelain and cast metal crowns, and implant supported crowns.

Exclusions: the following implant related procedures are excluded: implant maintenance, repairs, re-cement/re-bond, removal of implants, implant and abutment supported fixed partial denture retainers, and implant/abutment supported removable dentures.

$175 per calendar year. Reimbursement of fees to qualified health clubs, participation in instructional fitness classes, nutritional counseling, memory fitness activities, wellness programs, activity tracker (every 3 years), additional acupuncture services beyond Medicare coverage, and more.

$150 per calendar year. Reimbursement for program fees for weight loss programs such as Weight Watchers or hospital-based weight loss programs. Does not include meals or other program items, such as scales.

You receive a SilverSneakers fitness membership at no additional cost giving you access to 16,000+ gyms nationwide, trained instructors, classes and health and nutrition tips with exercise videos.

$67 every calendar quarter for the purchase of covered over-the-counter (OTC) items such as bandages and toothbrushes. Members receive an OTC card loaded quarterly with credit to use towards covered OTC items at participating retailers and plan approved online stores. No rollover of unused quarterly balances. See Evidence of Coverage (EOC) for more information. 

$20 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. Additional acupuncture services are eligible for reimbursement under your Wellness Allowance.

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 Hearing Care Solutions formulary and must be purchased through Hearing Care Solutions. Different copays apply.

$250 Standard Level

$475 Superior Level

$650 Advanced Level

$850 Advanced Plus Level

$1,150 Premier Level

$150 annual allowance through EyeMed; $90 per calendar year for non-Eyemed provider. Use for standard eyeglasses (prescription lenses, frames, or a combination of lenses and frames) and/or contact lenses.