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TTY/TDD Phone: 1-800-735-2900
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Benefit Summary
| Annual Costs | 2009 Coverage | 2010 Coverage |
|---|---|---|
Annual deductible |
None |
$0 |
Annual out-of-pocket maximum |
$1,000 per person per year |
$1,000/person |
Annual prescription drug deductible |
Does not apply |
Does not apply |
| Medical Benefits | 2009 Coverage | 2010 Coverage |
|---|---|---|
Ambulance services |
||
(air) |
$75 copay |
$75/trip |
(ground) |
$75 copay |
$75/trip |
Diagnostic tests, laboratory, and X-rays |
Plan pays 100% |
Enrollee pays $0 |
Durable medical equipment, supplies, and prostheses |
Plan pays 100% |
Enrollee pays $0 |
Emergency room (copay waived if admitted) |
$50 copay per visit |
$50 |
Hearing |
||
(routine annual exam) |
$15 copay per exam |
$30 |
(hardware) |
Not covered |
Enrollee pays full cost |
Hospital services |
||
(inpatient) |
$200 copay per admission |
$200 per admission |
(outpatient) |
$50 copay |
$50 |
Mental health care |
||
(outpatient) |
$15 copay per visit |
$30 |
Obstetric care |
||
(inpatient) |
Information unavailable, contact your plan |
Information unavailable, contact your plan |
(outpatient) |
Information unavailable, contact your plan |
Information unavailable, contact your plan |
Office visits |
$15 copay per visit |
$30 primary |
Physical, occupational, and speech therapy (per-visit cost for 60 visits/year combined) |
Inpatient Outpatient |
Enrollee pays $30 (outpatient copay) |
Prescriptions |
||
tier 1 (retail pharmacy, 30-day supply) |
Enrollee pays 40% coinsurance to $150 maximum per prescription or refill Medicare-approved diabetic supplies: same as any other prescription drug |
40% to $150 maximum |
tier 2 (retail pharmacy, 30-day supply) |
Enrollee pays 40% coinsurance to $150 maximum per prescription or refill |
40% to $150 maximum |
tier 3 (retail pharmacy, 30-day supply) |
Not covered |
N/A |
tier 1 (mail order, 90-day supply) |
Enrollee pays 40% coinsurance to $300 maximum per prescription or refill Medicare-approved diabetic supplies: same as any other prescription drug |
40% to $300 maximum maintenance Rx; |
tier 2 (mail order, 90-day supply) |
Enrollee pays 40% coinsurance to $300 maximum per prescription or refill |
40% to $300 maximum maintenance Rx; |
tier 3 (mail order, 90-day supply) |
Not covered unless meets medical necessity criteria |
N/A |
Preventive care |
$15 copay per visit |
$30 |
Spinal manipulations (per-visit cost for 10 visits/year) |
$15 copay per visit, up to 10 visits per calendar year |
$30 |
Vision care |
||
(annual exam) |
$15 copay per exam; no visit limit for routine eye exams |
$30 |
(glasses and contact lenses) |
Hardware every 24 months; either lenses and frames, or contact lenses. $150 plan maximum Hardware after cataract surgery (either lenses and frames, or contact lenses): Plan pays 100% Amount over standard charges not covered |
Enrollee pays any amount over $150 every 24 months |
