Compare Plans


2021 Plan Year

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

$0

$50 $100

$0

 

$50

 

Annual Out-of-Pocket Maximum (Does not include Part D Rx.) $5,600 $4,900 $3,450

$4,900

 

$3,450
Primary Care Visit Copay $15 $10 $5 $10 $5
Specialist Visit Copay $50 $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 1-8: $270/day

Days 9+: $0

Days 1-7: $200/day

Days 8+: $0

$250/stay

Days 1-7: $200/day

Days 8+: $0

$250/stay
Outpatient Surgery 1

Copay $300 ASC/
$300 hospital

Copay $150 ASC/
$250 hospital

Copay $0 ASC/$100 hospital

Copay $150 ASC/$250 hospital

 

Copay $0 ASC/
$100 hospital
Preventive Services 2
Skilled nursing facility Copay3

Days 1-20: $0

Days 21-100: $184/day

Days 1-20: $0

Days 21-100: $170/day

Days 1-20: $0

Days 21-100: $170/day

Days 1-20: $0

Days 21-100: $170/day

Days 1-20: $0

Days 21-100: $170/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 $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: $25
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: $25
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: $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: $15 12 (60-minute) visits per year: $10 12 (60-minute) visits per year: $0 12 (60-minute) visits per year: $10 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: $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 $40 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.