Metro Denver/Boulder Green Plan (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.
- Free annual physical and preventive care
- Vision screening
- Emergency and urgent care (U.S. and 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 services. |
| 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, Worldwide
|
|
Inpatient Hospital Copayment
|
$210 per day, day 1-7
$0 copay days 8-90
|
|
Outpatient Surgery
|
$350 per visit
|
|
Ambulance
|
$150 per trip
|
|
Emergency Room
|
$50 per visit, Worldwide
|
|
Urgent Care
|
$30 per visit, Worldwide
|
|
Part D Prescription Drug Benefit
|
$120 Deductible - brand 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 for the Metro Denver/Boulder area.
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.
- 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 12/28/09. 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.
CMS122809 S5860_H0602_1037014 MC150WEB