The Comprehensive, Plus, and Premium plans supplement medical benefits provided by Medicare Part A and Part B. They also provide benefits for an annual physical, vision, and pharmacy benefits. You may choose whether to include pharmacy benefits in your plan.
With each plan, you will be responsible for some out-of-pocket expenses. (Your prescription drug retail deductible and copayments do not count toward the annual out-of-pocket maximums.)
| Benefits | What Medicare Asks You to Pay |
What You'll Pay in the Comprehensive Plan |
What You'll Pay in the Plus Plan | What You'll Pay in the Premium Plan |
|---|---|---|---|---|
| Annual Out-of-Pocket Maximums |
No maximum limit | For Part A and Part B benefits: Individual: $2,000 | For Part A and Part B benefits: Individual: $1,750 | For Part A and Part B benefits: Individual: $1,500 |
| Medicare Limitations | Expenses are approved when Medicare deems the benefits to be medically necessary. Care not covered/approved by Medicare will not be covered. | All medical benefits are limited to expenses approved by Medicare. | ||
| Inpatient Days 1-60* |
For each benefit period, you pay the first $1,100. This is your Part A deductible. | You pay up to $390 per benefit period. All other costs are covered at 100%. | You pay up to $150 per benefit period. All other costs are covered at 100%. | You pay nothing. |
| Inpatient Days 61-90* |
$277 per day | You pay nothing. | ||
| Inpatient Days 91-150* |
$550 per day | You pay nothing. | ||
| Skilled Nursing Facility Days 1-20* |
You pay nothing. | You pay nothing. | ||
| Skilled Nursing Facility Days 21-100* |
$137.50 per day; 100-day benefit limit |
You pay nothing. | You pay nothing. | You pay nothing. |
*Limited to expenses approved by Medicare
| Benefits | What Medicare Asks You to Pay |
What You'll Pay in the Comprehensive Plan |
What You'll Pay in the Plus Plan | What You'll Pay in the Premium Plan |
|---|---|---|---|---|
| Home Health Care | You pay nothing. | You pay nothing for services approved by Medicare. | ||
| Durable Medical Equipment | You pay 20% of the Medicare-approved amount | You pay nothing. | You pay nothing. | You pay nothing. |
| Medicare Part B Physician Office Visits | You pay 20% after the $155 deductible. | You pay up to $20 per office visit. | You pay up to $15 per office visit. | You pay up to $15 per office visit. |
| Diagnostic Laboratory Services | You pay 100% of the Medicare-approved amount after the annual Part B deductible. | You pay nothing. | You pay nothing. | You pay nothing. |
| Other Medicare Part B Services | You pay a coinsurance or copayment amount, which may vary according to the service. | You pay 30% of the remaining Medicare coinsurance. | You pay 20% of the remaining Medicare coinsurance. | You pay 20% of the remaining Medicare coinsurance. |
| Outpatient Hospital Services | You pay a coinsurance or copay amount, which may vary according to the service. | You pay up to $275 of any Medicare coinsurance or copayment. | You pay up to $275 of any Medicare coinsurance or copayment. | You pay up to $175 of any Medicare coinsurance or copayment. |
| Routine Physical Exam Office Visit | Not covered. You pay 100%. | You pay nothing up to $200. | ||
| Benefits | What Medicare Asks You to Pay |
What You'll Pay in the Comprehensive Plan |
What You'll Pay in the Plus Plan | What You'll Pay in the Premium Plan |
|---|---|---|---|---|
| Routine Clinical Laboratory Services & Diagnostic Tests (Performed With Your Routine Physical) | You pay a coinsurance or copayment amount, which may vary according to the service and may or may not be subject to the Part B deductible. | You pay nothing for clinical laboratory services associated with your routine physical, including, but not limited to, bone mass measurements, colorectal screening, mammograms, Pap smears, pelvic exams, and prostate cancer screening. | ||
| Medicare-Approved Chiropractic Services | You pay 20% of the Medicare-approved amount. | You pay 30% of the remaining Medicare coinsurance (i.e., 6% of the total Medicare-approved amount). | You pay 20% of the remaining Medicare coinsurance (i.e., 4% of the total Medicare-approved amount). | You pay nothing. |
| Prescription Drugs: Medco | See Medicare prescription drug plan information. | See the Prescription Drug Benefits Summary  |
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| Vision: EyeMed | Not covered (You pay 100%). | 12-month benefit for:
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Notes:
1. The Prescription Drug Benefit information is only applicable to the Medicare Supplement plans with the pharmacy benefit option.
2. This vision information describes the in-network benefit. See the plan document handbook for details about non-network vision benefits.
3. Vision copayments and the prescription drug deductibles & copayments do not apply to the annual out-of-pocket maximum.
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