Find out about this planâs copays for primary care providers and specialists.
Costs | In-network - what you'll pay | Out-of-network - what you'll pay |
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Primary care provider (PCP) | $0 copay | $0 copay |
Primary care provider (PCP) $0 copay$0 copay | ||
Specialist | $0 copay | $0 copay |
Specialist $0 copay$0 copay | ||
Virtual visits | $0 copay to talk with a telehealth provider online through live audio and video. | |
Virtual visits $0 copay to talk with a telehealth provider online through live audio and video.$0 copay to talk with a telehealth provider online through live audio and video. | ||
Annual routine physical 4 | $0 copay, 1 per year | 40% of the cost, combined visits in and out-of-network |
Annual routine physical 4 $0 copay, 1 per year40% of the cost, combined visits in and out-of-network | ||
Preventive services (such as covered screenings, vaccinations, etc.) 2 | $0 copay for covered services | $0 copay for covered services |
Preventive services (such as covered screenings, vaccinations, etc.) 2 $0 copay for covered services$0 copay for covered services | ||
Mental health (outpatient) | $0 copay | $0 copay |
Mental health (outpatient) $0 copay$0 copay | ||
Opioid treatment services | $0 copay | $0 copay |
Opioid treatment services $0 copay$0 copay |
Learn about this plan's prescription drug coverage and costs. Enter your prescriptions to see what they'd cost with this plan.
Costs | What you'll pay |
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Annual prescription deductible
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Annual prescription deductible
If your plan has an annual deductible, you (or others on your behalf) will pay your drug costs up to the amount of this deductible before moving into the Initial Coverage stage.
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$0 |
Annual prescription deductible
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Annual prescription deductible
If your plan has an annual deductible, you (or others on your behalf) will pay your drug costs up to the amount of this deductible before moving into the Initial Coverage stage.
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Covered Insulin |
Network pharmacy (30-day) No more than $35 copay Standard mail order pharmacy (100-day) No more than $105 copay |
Covered Insulin
Network pharmacy (30-day) No more than $35 copay Standard mail order pharmacy (100-day) No more than $105 copay |
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Initial Coverage stage - no Extra Help |
Network pharmacy (30-day) 25% coinsurance Standard mail order pharmacy (100-day) 25% coinsurance |
Initial Coverage stage - no Extra Help
Network pharmacy (30-day) 25% coinsurance Standard mail order pharmacy (100-day) 25% coinsurance |
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Initial Coverage stage - if you qualify for Extra Help |
Generic (including brand drugs treated as generic) $0 All other drugs $0 |
Initial Coverage stage - if you qualify for Extra Help
Generic (including brand drugs treated as generic) $0 All other drugs $0 |
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Coverage Gap stage 6 | During the Coverage Gap stage, the plan pays all of the cost of your drugs. |
Coverage Gap stage 6 During the Coverage Gap stage, the plan pays all of the cost of your drugs. | |
Catastrophic Coverage stage | During the Catastrophic Coverage stage, the plan pays all of the cost for your drugs |
Catastrophic Coverage stage During the Catastrophic Coverage stage, the plan pays all of the cost for your drugs |
Learn about this planâs dental coverage options and costs.
Costs | What you'll pay |
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Routine dental | No coverage |
Routine dental No coverage |
See this plan's benefits, costs and copays. For full plan details, see the Evidence of Coverage or Summary of Benefits under the Plan Documents section.
Costs | In-network - What you'll pay | Out-of-network - What you'll pay |
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Urgent care | $0 copay per visit ($0 copay when outside of the United States) | |
Urgent care $0 copay per visit ($0 copay when outside of the United States)$0 copay per visit ($0 copay when outside of the United States) | ||
Emergency care | $0 copay per visit ($0 copay when outside of the United States) | |
Emergency care $0 copay per visit ($0 copay when outside of the United States)$0 copay per visit ($0 copay when outside of the United States) | ||
Ambulance services | $0 copay for ground or air | $0 copay for ground or air |
Ambulance services $0 copay for ground or air$0 copay for ground or air | ||
Inpatient hospital care | $0 per stay for unlimited days | $0 per stay for unlimited days |
Inpatient hospital care $0 per stay for unlimited days$0 per stay for unlimited days | ||
Outpatient hospital services (including surgery and observation) 2 | $0 copay | $0 copay |
Outpatient hospital services (including surgery and observation) 2 $0 copay$0 copay | ||
Ambulatory surgical center 2 | $0 copay | $0 copay |
Ambulatory surgical center 2 $0 copay$0 copay | ||
Physical, speech or occupational therapy | $0 copay per visit | $0 copay per visit |
Physical, speech or occupational therapy $0 copay per visit$0 copay per visit | ||
Lab services | $0 copay | $0 copay |
Lab services $0 copay$0 copay | ||
Outpatient X-rays | $0 copay | $0 copay |
Outpatient X-rays $0 copay$0 copay | ||
Diagnostic tests and procedures, non-radiological (such as EKG/ECG tests, etc.) | $0 copay | $0 copay |
Diagnostic tests and procedures, non-radiological (such as EKG/ECG tests, etc.) $0 copay$0 copay | ||
Diagnostic radiology services (such as MRIs, CT scans, etc.) | $0 copay | $0 copay |
Diagnostic radiology services (such as MRIs, CT scans, etc.) $0 copay$0 copay | ||
Skilled nursing facility | $0 copay per day: days 1-100 | $0 copay per day: days 1-100 |
Skilled nursing facility $0 copay per day: days 1-100$0 copay per day: days 1-100 | ||
Home health care | $0 copay | $0 copay |
Home health care $0 copay$0 copay | ||
Diabetes monitoring supplies 2 | $0 copay for covered brands | $0 copay |
Diabetes monitoring supplies 2 $0 copay for covered brands$0 copay |
See more of the benefits and programs offered by this plan that are not provided under Original Medicare. For full plan details, see the Evidence of Coverage or Summary of Benefits under the Plan Documents section.
Costs | In-network - What you'll pay | Out-of-network - What you'll pay |
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Routine eye exam 3 | No coverage | No coverage |
Routine eye exam 3 No coverageNo coverage | ||
Food, OTC and utility bill credit 4 | $44 credit every month to pay for covered healthy food, OTC products and utility bills from network utility companies. | |
Food, OTC and utility bill credit 4 $44 credit every month to pay for covered healthy food, OTC products and utility bills from network utility companies.$44 credit every month to pay for covered healthy food, OTC products and utility bills from network utility companies. | ||
Routine foot care 3 | $0 copay, 4 visits per year | 40% of the cost, combined visits in and out-of-network |
Routine foot care 3 $0 copay, 4 visits per year40% of the cost, combined visits in and out-of-network | ||
Nurse Hotline 3 | Speak with a registered nurse (RN) 24 hours a day, 7 days a week. | |
Nurse Hotline 3 Speak with a registered nurse (RN) 24 hours a day, 7 days a week.Speak with a registered nurse (RN) 24 hours a day, 7 days a week. |
Important documents that provide the details you need about this plan's coverage and benefits, prescription drugs, enrollment, providers and more.
General Plan Information |
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General Plan Information
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Provider Directory | |
Provider Directory | |
Prescription Drug Coverage |
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Prescription Drug Coverage
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Pharmacy Directory | |
Pharmacy Directory |
General Plan Information |
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General Plan Information
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Provider Directory |
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Provider Directory
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Prescription Drug Coverage |
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Prescription Drug Coverage
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Pharmacy Directory | |
Pharmacy Directory |
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