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

$31 $71

$0

$30
Annual Out-of-Pocket Maximum (Does not include Part D Rx.) $5,900 $4,900 $3,450 $4,900 $3,450
Primary Care Visit Copay $0 $0 $0 $0 $0
Specialist Visit Copay $45 $35 $25 $35 $25
Urgent Care (worldwide) $50/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 $15 $10 $5 $10 $5
Inpatient Hospital Coverage Copay

Days 1-5: $370/day

Days 6+: $0

Days 1-7: $275/day

Days 8+: $0

$325/stay

Days 1-7: $275/day

Days 8+: $0

$325/stay
Outpatient Surgery 1 $250 per surgery $200 per surgery $150 per surgery $200 per surgery $150 per surgery
Preventive Services 2
Skilled nursing facility Copay3

Days 1-20: $0

Days 21-100: $170/day

Days 1-20: $0

Days 21-100: $160/day

 

 

Days 1-20: $0

Days 21-100: $150/day

Days 1-20: $0

Days 21-100: $160/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 $48.10 $48.10 $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 $100 per year
for frames, lenses, and contacts
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 $100 per year
for frames, lenses, and contacts
Initial routine eye exam each year:
$0 copay
Plan pays $100 per year
for frames, lenses, and contacts
Hearing copay Annual hearing exam: $45
Hearing aids: $700-$1,050 per aid
Limit: 1 per ear, per year
Annual hearing exam: $35
Hearing aids: $700-$1,050 per aid
Limit: 1 per ear, per year
Annual hearing exam: $25
Hearing aids: $700-$1,050 per aid
Limit: 1 per ear, per year
Annual hearing exam: $35
Hearing aids: $700-$1,050 per aid
Limit: 1 per ear, per year
Annual hearing exam: $25
Hearing aids: $700-$1,050 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 N/A N/A N/A N/A N/A
Travel Benefits9
Fitness Benefit10

Looking for pharmacy benefits information? Check out our drug coverage page.

2 Includes annual check and Medicare-approved vaccines, screenings, and tests

4 See the chart

5 Get reimbursed for dental services from a dentist you choose. Reimbursement limits: Core D=$300/Value D=$500/Elite D=$700/Value = $500/Elite=$700

7 Covers $50 OTC health-related items per quarter

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

10 $25/month reimbursement for an licensed facility

This webpage was updated on October 19, 2020.