Plan Premiums and Other Costs
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Monthly premium
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$49
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Maximum out of pocket limit
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$10,000 in-network and out-of-network combined
$4,300 in network
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Annual deductible
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$0
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Benefits and Costs
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In-Network
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Point-of-Service
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Primary care physician visit
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$0 copay
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30% coinsurance
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Specialist visits
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$40 copay
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30% coinsurance
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Preventive care
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$0 copay
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30% coinsurance
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Inpatient hospital coverage
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$310 per day for days 1 - 7
$0 per day for days 8 and after
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30% coinsurance
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Outpatient surgery - hospital
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$275 copay
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30% coinsurance
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Outpatient surgery - ambulatory surgical center
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$250 copay
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30% coinsurance
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Emergency care
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$100 copay in or out of network
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Urgent care
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$50 copay in or out of network
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Ambulance
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$220 copay
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Lab services
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$0 copay
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30% coinsurance
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Diagnostic tests & procedures
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$30 copay
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30% coinsurance
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Diagnostic radiology services (MRI, CT scan)
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$150 copay
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30% coinsurance
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Standard X-rays
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$25 copay
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30% coinsurance
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Over-the-counter allowance
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$225/quarter with no rollover
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Preventive dental
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$0 copay for:
- 2 exams and 2 cleaned (regular or periodontal) each year
- 1 fluoride treatment each year
- One set of bitewing X-rays each year (not payable in the same calendar year as a full mouth X-ray)
- Full mouth X-rays once every 5 years
- Emergency palliative treatment
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Not covered
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| Comprehensive dental |
$50 percent coinsurance for:
- Fillings and crown repairs
- Periodontal non-surgical procedures (covered once per quadrant per 24-month period)
- Simple extractions
$0 copay for brush biopsies
$40 copay for Medicare-covered dental services
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Not covered |
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Eyewear
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$0 copay for up to a maximum of $300 each year for routine corrective eyeglasses (lenses and frames) or contact lenses
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30% coinsurance
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Chiropractic services
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$20 copay
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30% coinsurance
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Acupuncture services
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$25 copay
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Not covered
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Fitness membership
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Up to $200 annually
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Virtual care with McLarenNow
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$0 copay
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Not covered
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Hearing aid
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$699 copayment per aid for Advanced Aids
$999 copayment per aid for Premium Aids
$50 additional cost per aid for optional hearing aid rechargeability
Up to two TruHearing-branded hearing aids, one per ear every two years. Benefit is limited to TruHearing’s Advanced and Premium hearing aids. Must use TruHearing providers.
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Not covered
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Worldwide emergency or urgent care
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$100 emergency copay
$50 urgent care copay
You may receive covered emergency and urgent care services anywhere in the world. If you are outside of the United States or its territories, your worldwide emergency and urgent care coverage is limited to $50,000
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| Personal Emergency Response System (PERS) |
$0 copay for a Mobile PERS plus device equipped with two-way voice communication, GPS location technology, and the option of auto fall detection with 24/7 monitoring |
| Transportation |
$0 copay for up to 30 one-way non-emergency trips per year to plan approved health-related locations. 50 mile limit one-way. |
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Meals after discharge
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28 meals (2 meals per day for 14 days) delivered directly to your home after each discharge from an inpatient acute or a skilled nursing facility stay. Annual limit of 5 discharges for a total of 140 meals per year.
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Part D Prescription Drug Coverage
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Deductible Stage
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There is no Part D deductible
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Initial Coverage Stage
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Tier 1 (preferred generics)
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$0
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Tier 2 (generics)
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$12 Insulins: $10
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Tier 3 (preferred brand)
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$47 Insulins: $35
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Tier 4 (non-preferred brand)
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$100
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Tier 5 (specialty drugs)
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33% of the cost
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Tier 6 (select care drugs)
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$0
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Coverage Gap Stage
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Once your total drug cost (what you pay plus what we pay) reaches $5,030, you will move into the Coverage Gap Stage where you will continue to pay your copay for drugs on Tier 1 and Tier 6. For all other generics, you will pay 25% of the price. For brand name drugs, you will pay 25% of the price plus a portion of the dispensing fee.
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Catastrophic Stage
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Once your yearly out-of-pocket drug costs total $8,000, our plan will pay the full cost for your covered Part D drugs.
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