Compare Plans


2021 Plans

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

$0

$40 $143 $20 $110
Annual Out-of-Pocket Maximum (Does not include Part D Rx.) $5,900 $3,450 $3,000 $3,450 $3,000
Primary Care Visit Copay $25 $15 $5 $15 $5
Specialist Visit Copay $50 $40 $30 $40 $30
Urgent Care (worldwide) $65/visit $40/visit $30/visit $40/visit

$30/visit

Emergency Copay (worldwide) $90/visit $90/visit $90 visit $90/visit $90/visit
Lab Services Copay $8 $4 $2 $4 $2
Inpatient Hospital Coverage Copay

Days 1-8: 270/day

Days 9+: $0

Days 1-8: $200/day

Days 9+: $0

 

$250/stay

Days 1-8: $200/day

Days 9+: $0

$250/stay
Outpatient Surgery 1 $250 per surgery $100 per surgery $50 per surgery $100 per surgery $50 per surgery
Preventive Services 2
Skilled nursing facility Copay3

Days 1-20: $0 copay

Days 21-100: $178/day

Days 1-20: $0 copay

Days 21-100: $150/day

Days 1-20: $0 copay

Days 21-100: $150/day

Days 1-20: $0 copay

Days 21-100: $150/day

Days 1-20: $0 copay

Days 21-100: $150/day

Prescription Drug Coverage4 N/A N/A
Dental Benefit5 $250 annual limit $350 annual limit $550 annual limit $350 annual limit $550 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 $150 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 $150 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: $10
Hearing aids: $675-$1,200 per aid
Limit: 1 per ear, per year
Annual hearing exam: $0
Hearing aids: $675-$1,200 per aid
Limit: 1 per ear, per year
Annual hearing exam: $0
Hearing aids: $675-$1,200 per aid
Limit: 1 per ear, per year
Annual hearing exam: $0
Hearing aids: $675-$1,200 per aid
Limit: 1 per ear, per year
Annual hearing exam: $0
Hearing aids: $675-$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: $15 12 (60-minute) visits per year: $0 12 (60-minute) visits per year: $15 12 (60-minute) visits per year: $0
Meal Delivery8 N/A
Telehealth/Virtual Visits Copay
Travel Benefits9
Fitness Benefit10

For pharmacy benefits information, visit our page on drug pricing.

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

3 An initial 3-day hospital stay is required

See chart

5 Reimbursement Limits by plan: Core D: $250/Value D: $350/Elite D: $550/Value: $350/Elite: $550

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

7 Covers $25 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 October 19, 2020.