Metro Denver/Boulder Standard Plan + Rx (Cost) Coverage
Standard Plan + Rx (Cost) – $118.20/month
Standard Plan (Cost)* – $64.00/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 (U.S.)
| Medicare Covered Benefit | Standard Plan + Rx (Cost)
You Pay |
| Monthly Health Plan Premium |
|
| Medical Prescription Drug Total | $64.00 $54.20 $118.20 * plus you must continue to pay Medicare Part B
premium |
| Primary Care Physician
Office Visit Copayment | $20 per visit |
| Specialist Care Physician
Office Visit Copayment | $40 per visit |
| Inpatient Hospital Copayment | $550 per admission |
| Outpatient Surgery | $300 per visit |
| Ambulance | $100 per trip |
| Emergency Room | $50 per visit
within the United States |
| Urgent Care | $40 per visit
within the United States |
| Part D Prescription Drug Benefit | No deductible
$10 copay generic $40 copay preferred brand $60 copay nonpreferred brand 33% specialty
After $2,830 in retail 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 1-14 days $95 days 15-100 days |
| 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 Standard Plan + Rx (Cost) that includes Part D coverage.
Standard 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 discount
- Vision discount program
- Hearing discount program
- Discounts on complementary care, for example: chiropractic and massage therapy
- Silver&Fit Affinity walking program to support wellness
- Optional dental plan
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.
