In-network deductible
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$0
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| Out-of-pocket limit |
$3,400 for in-network services
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Inpatient hospital care
There is no limit to the number of days covered by the plan. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.
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In-network:
$800 copay for each Medicare-covered hospital stay
Out-of-network
30% of the cost for each Medicare-covered hospital stay |
| Doctor office visits |
In-network doctors
$20 copay for each primary care doctor visit for Medicare-covered benefits
$45 copay for each specialist visit for Medicare-covered benefits
Out-of-network doctors
30% of the cost of each doctor visit (primary care or specialist)
Authorization rules may apply. |
Diagnostic tests, x-rays, lab services, and radiology
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In-network
$0 to $25 copay for Medicare-covered lab services
$0 to $25 copay for Medicare-covered diagnostic procedures and tests
$25 copay for Medicare-covered x-rays
$175 copay for Medicare-covered diagnostic radiology services (not including x-rays)
$25 copay for Medicare-covered therapeutic radiology services
If the doctor provides you services in addition to outpatient diagnostic procedures, tests and lab services, separate cost sharing of $20 to $45 may apply.
If the doctor provides you services in addition to outpatient diagnostic and therapeutic radiology services, separate cost sharing of $20 to $45 may apply.
Out-of-network
30% of the cost for therapeutic radiological services
30% of the cost for outpatient x-rays
30% of the cost for diagnostic radiological services
30% of the cost for outpatient diagnostic procedures/tests/lab services
Authorization rules may apply. |
| Preventive services and programs |
$0 copay for all preventive services covered under Original Medicare at zero cost sharing, and additional services. Authorization rules may apply.
Abdominal aortic aneurysm screening
Alcohol misuse screening and behavioral counseling interventions in the primary care setting
Annual physical exam
Behavioral therapy for cardiovascular disease, intensive, bi-annual
Behavioral therapy for obesity, intensive
Breast cancer screening (mammogram)
Bone mass measurement
Cardiovascular screening
Cervical and vaginal cancer screening
Colorectal cancer screening
Depression screening for adults
Diabetes screening
Influenza vaccine
Hepatitis B vaccine
HIV screening
Medical nutrition therapy services
Personalized prevention plan services (annual wellness visits)
Pneumococcal vaccine
Prostate cancer screening (prostate specific antigen (PSA) test only)
Sexually transmitted diseases (STIs): Screening for, and counseling to prevent
Smoking and tobacco cessation
Telemonitoring services
Welcome to Medicare preventive visit (initial preventive physical exam)
In-network
The plan covers the following supplemental education/wellness programs:
Health education, nutritional education, and health club membership/fitness classes |
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Part D prescription drugs
This plan uses a list of approved drugs, or "formulary." The plan will send you the formulary. You can also see the formulary on this website.
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$0 deductible
Initial coverage at in-network pharmacies (What you pay in 2013 until your total drug costs reach $2,970):
Generic drugs (tier 1): $9 copay for a for a 31-day supply, $27 copay for a 90-day supply
Preferred brand drugs (tier 2): $40 copay for a for a 31-day supply, $120 copay for a 90-day supply
Non-preferred brand drugs (tier 3): $90 copay for a for a 31-day supply, $270 copay for a 90-day supply
Specialty drugs (tier 4): 33% coinsurance (you pay 33%, Priority Health pays 67%) for a for a 31-day supply
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| Dental services |
In-network
$0 copay for:
Up to 1 oral exam(s) every year
Up to 1 cleaning(s) every year
50% of the cost for 1 dental x-ray every year
$45 copay for Medicare-covered dental benefits
Authorization rules may apply. |
Optional dental coverage
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$17 monthly premium, in addition to your monthly plan premium and the monthly Medicare Part B premium.
$1,000 plan coverage limit every year for these benefits
Covers:
100% coverage for two annual preventive oral exams and two annual dental cleanings
100% coverage for one set of dental x-rays annually
50% coverage for endodontic services
50% coverage for minor restorative fillings
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Silver&Fit® free fitness benefit
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The Silver&Fit® Basic program includes:
Membership at a local participating Silver&Fit fitness facility or exercise center
The Silver&Fit Home Fitness Program for members who are unable to participate in a fitness facility or prefer to work out at home
The Silver Slate® newsletter specifically designed for Silver&Fit members
A website designed specifically for Silver&Fit members
A toll-free customer service hotline for answers to questions about the program |