Summary of Benefits

Premium

$0 monthly plan premium

Doctor office visits

$0 copay for each Medicare-covered primary care provider (PCP) visit

Specialist visits

$0 copay for each Medicare-covered specialist visit

No referral required

Preventive and comprehensive dental

Unlimited amount each year for preventive dental services

$0 copay for the following preventive dental benefits:

• Up to one oral exam every six months
• Up to one cleaning every six months
• Up to one fluoride treatment every six months
• Up to four dental X-ray visits every five years (frequency varies by services)

The combined total comprehensive dental benefits cannot exceed $2,000 every year. The comprehensive dental benefits include the following services up to a $2,000 combined limit every year:

• minor restorations (fillings)
• extractions, one per tooth per liftime.
• dentures, one per arch every five years. Prior authorization is required.
• denture repair and reline, one per year.
• surgical extractions
• oral surgery
• periodontics
• endodontics
• crowns, one every five years, per tooth. No more than four per calendar year, with no more than two crowns per arch per year.
• mini-implants (lower arch only) and implant supported denture (lower arch only), one every five years.

*Prior authorization is required for dentures, periodontics, endodontics, crowns, mini-implants, and implant-supported dentures. Fixed bridges and all other dental implants, except for mini-implants, are not covered.

Hearing

Diagnostic hearing and balance evaluations performed by your PCP to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider.

• $0 for up to one routine hearing exam every year
• $1,200 allowance for two non-implantable TruHearing Branded Advanced hearing aids every three years (limit 1 hearing aid per ear). After plan-paid benefit, you are responsible for the remaining costs.*
  • You must see a TruHearing provider to use this benefit.
  • Each TruHearing-branded hearing aid purchase includes one year of follow-up provider visits for fitting and adjustments. These visits are available for 12 months following the purchase of a TruHearing branded hearing aid purchase while the member is enrolled in the plan.

Hearing aid purchase includes:

• First 12 months of follow-up provider visits
• 60-day trial period
• 3-year extended warranty
• 80 batteries per aid for non-rechargeable models

Benefit does not include or cover any of the following:

• Over the counter (OTC) hearing aids, Ear molds, Hearing aid accessories, Additional provider visits, Additional batteries, batteries when a rechargeable hearing aid is purchased, Hearing aids that are not TruHearing-branded Advanced Aids, Costs associated with loss & damage warranty claims

Costs associated with excluded items are the responsibility of the member and not covered by the plan.

• * Remaining costs refers to any amount in excess of your allowance

You must receive your care from a network provider. We will only pay for covered hearing services if you go to an in-network hearing provider. In most cases, you will have to pay for care that you receive from an out-of-network provider.

Vision services

Covered services include:

• Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts.
• For people who are at high risk of glaucoma, we will cover one glaucoma screening each year. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older.
• For people with diabetes, screening for diabetic retinopathy is covered once per year.
• One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.)

Our plan offers supplemental vision coverage including:

• $0 copay for up to one routine vision exam every year.
• In addition to the cataract surgery benefit, the plan will cover up to $200 every year towards eyeglasses or contact lenses.

You must receive your care from a network provider. We will only pay for covered vision services if you go to an in-network vision provider. In most cases, you will have to pay for care that you receive from an out-of-network provider.

Transportation

16 one-way trips to plan-approved locations every year (e.g., doctor's office, pharmacy, and hospital). May consist of a car, shuttle, or van service depending on appropriateness for the situation and the member's needs. Rides must be scheduled at least one business day in advance except in special circumstances.

Prior authorization is required for trips that exceed 50 miles for a one‐way ride. Other prior authorization and scheduling rules apply.

Over-the-counter (OTC)

$45 per month to spend on eligible OTC items such as vitamins, pain relievers, cold remedies, and more. Funds are loaded to a plan-issued debit card each month.

• Members can shop through the OTC catalog (PDF) or at participating retail stores
• No limit on the number of items or orders
• Unused amounts expire at the end of each month or upon disenrollment from the plan

Home health care

Outpatient mental health care

$0 copay for each Medicare-covered individual therapy visit

$0 copay for each Medicare-covered group therapy visit

$0 copay for each Medicare-covered individual therapy visit with a psychiatrist

$0 copay for each Medicare-covered group therapy visit with a psychiatrist

Important message about what you pay for vaccines

Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.