2019 Summary of Benefits

Dual Eligible Special Needs Plan

$0 Annual Premium*
$0 Deductible
Part D Prescription Drug Coverage
$0 Preventative Care and Screenings

Over-The-Counter Benefits

  • Up to $696 annual over-the-counter benefits
  • Covers health-related drugs and supplies including cough, cold and allergy medications, first aid supplies and much more at no cost

Dental Coverage

  • Up to $750 in preventive and comprehensive dental benefits annually
  • 2 oral exams and x-rays per year
  • 2 cleanings each year

Vision Coverage

  • 1 routine annual eye exam
  • $100 annual allowance for frames, lenses or contact lenses

Transportation

  • NA

Institutional Special Needs Plan

$0 Annual Premium*
$0 Deductible
Part D Prescription Drug Coverage
$0 Preventative Care and Screenings

Over-The-Counter Benefits

  • $58 per month over-the-counter drug benefit
  • Covers health-related drugs and supplies including cough, cold and allergy medications, first aid supplies and much more at no cost

Dental Coverage

  • 20% co-insurance of Medicare-covered services

Vision Coverage

  • 1 routine annual eye exam
  • $100 annual allowance for frames, lenses or contact lenses

Transportation

  • 24 one-way trips per year for non-emergency transportation (prior authorization required)

*Member must continue to pay their Medicare Part B premium

If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits. Or, use the Medicare Plan Finder on https://www.medicare.gov/find-a-plan/questions/home.aspx.

If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at https://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

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