Compare Plans


  CORE D (Includes Rx) With Rx VALUE D (Includes Rx) With Rx ELITE D (Includes Rx) With Rx VALUE ELITE
Monthly Premium

$0

$31 $70.90

$0

$40
Annual Out-of-Pocket Maximum (Does not include Part D Rx.) $5,900 $4,900 $3,900 $4,900 $3,900
Primary Care Visit Copay $0 $0 $0 $0 $0
Specialist Visit Copay $50 $35 $25 $35 $25
Urgent Care (worldwide) $60/visit $50/visit $40/visit $50/visit $40/visit
Emergency Copay (worldwide) $90/visit $90/visit $90/visit $90/visit $90/visit
Lab Services Copay $15 $10 $5 $10 $5
Inpatient Hospital Coverage Copay

Days 1-7: $295/day
Days 8+: $0

Days 1-7: $265/day
Days 8+: $0

$325/stay

Days 1-7: $265/day
Days 8+: $0

$325/stay

Outpatient Surgery 1 $275 per surgery $250 per surgery $200 per surgery $250 copay per surgery $200 per surgery
Preventive Services 2
Skilled nursing facility Copay3 Days 1-20: $0
Days 21-100: $184/day
Days 1-20: $0
Days 21-100: $184/day
Days 1-20: $0
Days 21-100: $150/day
Days 1-20: $0
Days 21-100: $184/day
Days 1-20: $0
Days 21-100: $150/day
Prescription Drug Coverage4 N/A N/A
Dental Benefit5 $300 annual limit $500 annual limit $700 annual limit $500 annual limit $700 annual limit
Optional Comprehensive Dental6 $48.10/month $48.10/month $48.10/month $48.10/month $48.10/month
Vision Benefit Initial routine eye exam each year:
$0 copay
Plan pays $100 per year
for frames, lenses, and contacts
Initial routine eye exam each year:
$0 copay
Plan pays $200 per year
for frames, lenses, and contacts
Initial routine eye exam each year:
$0 copay
Plan pays $300 per year
for frames, lenses, and contacts
Initial routine eye exam each year:
$0 copay
Plan pays $200 per year
for frames, lenses, and contacts
Initial routine eye exam each year:
$0 copay
Plan pays $300 per year
for frames, lenses, and contacts
Hearing copay Annual hearing exam: $0
Hearing aids: $700-$1,200 per aid
Limit: 1 per ear, per year
Annual hearing exam: $0
Hearing aids: $700-$1,200 per aid
Limit: 1 per ear, per year
Annual hearing exam: $0
Hearing aids: $700-$1,200 per aid
Limit: 1 per ear, per year
Annual hearing exam: $0
Hearing aids: $700-$1,200 per aid
Limit: 1 per ear, per year
Annual hearing exam: $0
Hearing aids: $700-$1,200 per aid
Limit: 1 per ear, per year
Over-the-Counter Benefit Card7
Massage Therapy for Chronic Conditions Copay 6 (60-minute) visits per year: $20 12 (60-minute) visits per year: $20 12 (60-minute) visits per year: $0 12 (60-minute) visits per year: $20 12 (60-minute) visits per year: $0
Meal Delivery8 N/A
Telehealth/Virtual Visits Copay
Travel Benefits9
Fitness Benefit10

Includes annual checkup and Medicare-approved vaccines, screenings, and tests.

3 A hospital stay is NOT required

See chart

5 Reimbursement Limits by plan: Core D: $300/Value D: $500/Elite D: $700/Value: $500/Elite: $700

6 Get an extra $1,000 in dental coverage for a monthly fee

7 Covers $50 OTC health-related items per quarter

8 20 meals delivered after a covered facility stay. Limited 4 times/year.

9 Get covered care when you travel at in-network costs for travel outside of Wisconsin, Illinois, Minnesota, or Iowa.*

10$25/month reimbursement for any licensed facility.

This webpage was updated on October 19, 2020.