Preventive Services (such as covered screenings, vaccinations, etc.) 2 $0 copay for covered services $0 copay - 40% of the cost (depending on the service) Preventive Services (such as covered screenings, vaccinations, etc.) Outpatient Hospital Services (includes observation services) 2 $0 copay - $295 copay $495 copay Outpatient Hospital Services (includes observation services) Opioid Treatment Services $0 copay $0 copay Mental Health (outpatient) Group: $15 copay $0 copay per day for unlimited days after that $0 copay per day for unlimited days after that $495 copay per day: Days 1-10 Inpatient Hospital Care $295 copay per day: Days 1-7 Home Health Care $0 copay 50% of the cost $90 copay per visit ($0 copay when outside of the United States)Īmbulance Services $250 copay for ground or air $250 copay for ground or air $0 copay for at least 3-month supply of Tier 1 medications with Preferred Mail Home Delivery from OptumRx.Īmbulatory Surgical Center 2 $0 copay - $245 copay $495 copayĭiabetes Monitoring Supplies 2 $0 copay for covered brands 50% of the costĭiagnostic Radiology Services (such as MRIs/CT scans, etc.)ĭiagnostic Radiology Services (such as MRIs/CT scans, etc.) $0 copay - $115 copay $200 copayĭiagnostic Tests and Procedures, non-radiological (such as EKG/ECG tests, etc.)ĭiagnostic Tests and Procedures, non-radiological (such as EKG/ECG tests, etc.) $20 copay $40 copayĮmergency Care $90 copay per visit ($0 copay when outside of the United States) $90 copay per visit ($0 copay when outside of the United States) Preferred Mail Home Delivery through OptumRx The money you spend using your card counts toward your out-of-pocket costs.Īfter your total out-of-pocket costs reach $7,400, you will pay the greater of $4.15 copay for generic (including brand drugs treated as generic), and $10.35 copay for all other drugs, or 5% coinsurance. Always use your Medicare Advantage member ID card during the coverage gap to get the plan's discounted drug rates. You may pay less if your plan has additional coverage in the gap. x Close Popupĭuring the Coverage Gap Stage, you (or others on your behalf) will pay no more than 25% of the price for generic drugs or 25% of the price (plus the dispensing fee) for brand name drugs, for any drug tier until the total amount you (or others on your behalf) have paid reaches $7,400 in year-to-date out-of-pocket costs. For all other plans: You will pay a maximum of $35 for each 1-month supply of Part D covered insulin drug through all coverage stages. If your plan has an annual deductible, you (or others on your behalf) will pay your drug costs up to the amount of this deductible before moving into the Initial Coverage stage.įor Chronic Special Needs plans: You will pay a maximum of $25 for each 1-month supply of Part D select insulin drug through all coverage stages.
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