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Monthly Premium Out-of-pocket Maximum Emergency Room PCP/Specialist Copay Hospital Copay Rx 30 Day CoPay Rx 30 Day CoInsurance Details Compare Apply Now View Comparison View Comparison Clear Close Print Return to Plans Self Enroll Short Form Add Enhanced Benefits: Option Added Add Option Not Available Best viewed in landscape Rotate your device for the best view 1 selected plan 2 selected plans 3 selected plans 4 selected plans Option A (+$45/mo) Option B (+$49/mo) Option C (+$43/mo) Dental & Vision coverage Dental, Vision, Hearing, Transportation & Meals Dental, Vision, Hearing, Transportation & Meals Benefit Information Important Information HMO Provider Network Prescription Drug Coverage Part D - Prescription Drug Coverage Retail Pharmacy Mail Order Pharmacy, 90-Day Supply Inpatient Care Doctor Office Visits Outpatient Care Outpatient Medical Services Additional Benefits Enhanced Benefits (Optional Add-Ons) Emergency Services Lab Services and Diagnostic Tests Medical Equipment and Supplies Rehabilitation Services Part B Drugs Wellness Exams and Screenings Vision Hearing Monthly Plan Premium Out-of-service area Health Plan Deductible Drug Deductible Drug Copay Drug Coinsurance Emergency Room Provider Network Details Option B Insulin Copay Other Option B Coinsurance Initial Coverage Threshold Mail Order Tier 1: Preferred Generic Mail Order Tier 2: Generic Mail Order Tier 3: Preferred Brand Mail Order Tier 4: Non-preferred Drug Mail Order Tier 5: Specialty Tier Mail Order Tier 6: Select Care Drugs Inpatient Hospital Inpatient Hospital Inpatient Hospital Skilled Nursing Facility (SNF) Skilled Nursing Facility (SNF) Primary Care Physician (PCP) Visit Specialist Visit Podiatry Services Telehealth Diabetic Supplies Diagnostic Tests & X-Rays Therapeutic radiology Lab Services Outpatient X-ray Diagnostic radiology Preventive Services Transportation To in-network appointments Covered visits per year (one-way trips) Acupuncture Medicare-covered benefits Covered visits per year Routine care Covered visits per year Chiropractic Services Medicare-covered benefits Routine care (limited to specific treatment codes) Covered visits per year Chiropractic (per routine visit) Dental Preventive services Home health services Outpatient mental health, outpatient substance abuse Ambulance, ground Diagnostic tests and procedures Lab services and X-rays Diabetes — monitoring, supplies, and therapeutic shoes Speech, physical, occupational, cardiac Pulmonary therapy Chemotherapy Part B insulin All other Part B drugs Medicare-covered preventive services Influenza vaccine (1 per year) Mammogram (1 per year) Diagnostic screenings (Medicare-covered benefits) Diagnostic hearing exams (Medicare-covered benefits) Outpatient hospital surgery/ambulatory surgical center This plan does not have a deductible. In-network only Not Covered Not available Combined In/Out Network in-network $115 Copay. If you are admitted to the hospital within 24 hours, the Copay is waived. $25 Copay. If you are admitted to the hospital within 24 hours, the Copay is waived $300 Copay per visit or 20% of the cost, depending on the service $0 Preventive Dental with Option month $0/12 visits In network, 30% Out of network $0 In Network, 30% Out of network