每月的保费
(你每月支付的金额.)
You must continue to pay your Medicare Part B premium. Low Income Subsidy can help pay for prescription drugs and monthly premiums. 了解更多. | $0 | $120 |
网络内自付最大值
(The most you pay each year for Medicare-covered services from in-network providers.) | $6,700 | $3,850 |
| 2024星级 |  4分(满分5星)H3832 [PDF]). |
| 澳门赌场赌大真钱玩法目录 | |
| 医疗福利* |
| | 你支付 | 你支付 |
| 年度扣除 | $0 | $0 |
| 住院治疗* | 第1至第6天:
370美元/天 第7至60天:
50美元/天 第61至90天:
0美元/天 | 第1至5天:
350美元/天 第6至90天:
0美元/天 额外的一天:
0美元/天 |
| 熟练护理机构* | 第1至20天:
0美元/天 第21至60天:
200美元/天 第61至100天:
0美元/天 | 第1至20天:
20美元/天 第21至40天:
190美元/天 第41至100天:
0美元/天 |
| Outpatient hospital facility and ambulatory surgical center services* | 20% | 20% |
| 初级保健提供者办公室访问 | $0 | $0 |
| Specialty care provider office visit | $50 | $30 |
| 年度健康访视 | $0 | $0 |
救护车服务
包括地面和空中. | $250 | $225 |
| 急救护理 | $100 | $100 |
| 紧急护理 | $50 | $30 |
| Worldwide coverage for emergency and urgent care services | 10% | 10% |
| Diagnostic tests and procedures, lab services, and outpatient X-rays* | 20% | 20% |
| 医疗保险B部分药物* | 20% | 20% |
| 医疗保险B部分胰岛素药物* | $35 | $35 |
| 医疗设备和用品* | 20% | 20% |
| 补充牙科福利 |
| 预防性牙科服务, including two oral exams every year, 每年清洗两次, 每年做一次x光检查, and two fluoride treatments every year | $0 | $0 |
| 综合牙科服务, including four extractions every year and two fillings every year | $0 | $0 |
| 综合牙科服务, including one root canal every year and one crown following a root canal on the same tooth every year | 不包括 | $0 |
| 牙科澳门赌场赌大真钱玩法目录 | 牙科医生目录[PDF] |
| 补充视力益处 |
| | 你支付 | 你支付 |
| 常规眼科检查 | 每日历年10/1次考试 | 每日历年$0/1考试 |
| 澳门赌场赌大真钱玩法 lenses and eyeglasses (frames and lenses) | $0
Plan pays up to $300 every calendar year | $0
Plan pays up to $300 every calendar year |
| 其他补充福利 |
Over-the-Counter (OTC) Health Products OTC health and wellness products available at select retail stores or through mail order delivery online at HMSAExtra 好处.com 或者通过呼叫 1-800-790-6019. 欲了解更多信息，请访问 scandeck.net/ Extra好处 | $0 该计划每季度支付65美元 | $0 该计划每季度支付95美元 |
Over-the-Counter (OTC) Health Products Catalog | Over-the-Counter (OTC) Health Products Catalog [PDF] |
健身-银牌&Fit Healthy Aging and Exercise Program
A membership to a participating fitness center, 每年一个家庭健身包, 健康老年辅导 sessions and more. | 健身中心会员资格
$0/month for standard fitness center,
$30- $200/month for premium fitness center 家庭健身套件
$0
1 家庭健身套件 per calendar year 健康老年辅导
$0 数字健身视频
$0 | 健身中心会员资格
$0/month for standard fitness center,
$30- $200/month for premium fitness center 家庭健身套件
$0
1 家庭健身套件 per calendar year 健康老年辅导
$0 数字健身视频
$0 |
远程医疗服务
包括 HMSA的在线护理. | $0 | $0 |
| 健康教育 | $0
了解更多 | $0
了解更多 |
| 健康指导 | $0
了解更多 | $0
了解更多 |
| 药物的好处 |
| | 你支付 | 你支付 |
年度扣除 Low Income Subsidy can help pay for prescription drugs and monthly premiums. 了解更多. | $380
Does not apply to tier 1 drugs, insulin and most D部分疫苗 | $0
|
初始覆盖阶段
Until total drug costs reach $5,030 |
| 30-day supply from retail pharmacies |
一级-首选通用 | $4.50 | $4 |
第2层-通用 | $12 | $11 |
三级-首选品牌 | $47 | $45 |
第3级-首选品牌胰岛素 | $35 | $35 |
第4层-非首选药物 | $100 | $95 |
5级-专精 | 27% | 33% |
第5级-专业胰岛素 | $35 | $35 |
| 100-day supply from mail-order pharmacy |
一级-首选通用 | $4.50 | $4 |
第2层-通用 | $12 | $11 |
三级-首选品牌 | $94 | $90 |
三级-首选品牌胰岛素 | $70 | $70 |
第4层-非首选药物 | $200 | $190 |
5级-专精 | 27% | 33% |
第5级-专业胰岛素 | $105 | $105 |
覆盖缺口阶段
Until your yearly out-of-pocket drug costs 达到8000美元 | 25% of the cost of brand or generic drugs |
| Additional gap coverage for Tier 1 drugs |
| 零售药房30天的供应量 | 不包括 | $4 |
| 100-day supply from mail-order pharmacy | 不包括 | $4 |
灾难覆盖阶段
After your yearly out-of-pocket drug costs
达到8000美元 | $0 for generic drugs (including brand drugs treated as generic) and all other drugs |
| D部分疫苗 | $0 for most D部分疫苗 on all drug tiers. |
| 药店 | 找药店 |
Prescription Drugs List (Formulary)
See if your prescription drugs are covered and search for lower-cost alternatives. 药物检索工具. | |
| 资源及计划资料 |
| 利益摘要 | 福利摘要[PDF] | 福利摘要[PDF] |
| 周年变更通知书 | 周年变更通知书[PDF] | 周年变更通知书[PDF] |
| 承保证明 | | |
| 成员资源 | 了解更多 | 了解更多 |
