Front Range Green Plan + Rx (Cost) Coverage
Green Plan + Rx (Cost) – $31.60/month
Green Plan (Cost)* – $0.00/ month
* Medical Only plans do not include the Part D prescription drug plan benefit.
Benefits May Include:
View plan details below for more information.
- Medicare Part D Prescription Drug Coverage
- Free annual physical and preventive care
- Vision screening
- Emergency and urgent care (Worldwide)
| Medicare Covered Benefit | Green Plan + Rx (Cost)
You Pay |
| Monthly Health Plan Premium |
|
| Medical Prescription Drug Total | $0.00
$31.60
$31.60 * plus you must continue to pay Medicare Part B
premium |
|
Medical deductible
|
$500 per calendar year. Includes all services except Preventive
Care, Primary Care Physician and Specialist Care office visits, lab services, and
Emergency room service.
|
|
Medical out of pocket maximum
|
$5,000 per calendar year for in-network Medicare-covered services. Medicare-covered
services do not include care received out of the country, routine vision or hearing
exams, annual physical, or hospice consultation.
|
| Primary Care Physician
Office Visit Copayment | $15 per visit |
| Specialist Care Physician
Office Visit Copayment | $30 per visit |
| Inpatient Hospital Copayment | $210 copay per day up to 7 days |
| Outpatient Surgery | $350 per visit |
| Ambulance | $150 per trip |
| Emergency Room | $50 per visit Worldwide |
| Urgent Care | $50 per visit Worldwide |
| Part D Prescription Drug Benefit | $120 Deductible- brand name drugs only
$12 copay generic
$36 copay preferred brand
$56 copay nonpreferred brand
30% specialty
After $2,830 in total drug expenses you pay 100% of cost until you reach $4,550
out of pocket drug costs
Beneficiary pays $2.50 copay generic; $6.30 copay for all other drugs; OR 5% (whichever is higher) |
| Annual Routine Physical Exam | $0 |
| Preventive Screening Services | $0 |
| Skilled Nursing Facility | $0 days 1-7 $100 days 8 -100 |
| Durable Medical Equipment | 20% |
Please refer to the
Plan Highlights Grid for a comparison listing of all Medicare
covered services and plan benefits.
Formulary
Click here to see the comprehensive list of prescription drugs covered
on the Green Plan + Rx (Cost) that includes Part D coverage.
Green Plan (Cost) Extras May Include:
The products and services described as extras are neither offered nor guaranteed
under our contract with the Medicare program. In addition, they are not subject
to the Medicare appeals process. Any disputes regarding these products and services
may be subject to the RMHP grievance process.
- Optional dental plan
- Prescription drug discounts
- Vision discount program
- Hearing discount program
- Discounts on complementary care, for example: chiropractic and massage therapy
- Silver&Fit Affinity walking program to support wellness
Click here for detailed information on the
Extras offered through the Medicare Plans
Information is current as of 05/18/10. Please call to confirm you have the most up to date information about our Medicare Plans. Click here for a full list of Medicare Disclaimers.
S5860_H0602_1307017 MC150WEB Pending CMS Approval 08312010.
