$11 per month (Includes pharmacy)

This plan does not have a medical deductible.

Annual Maximum Out-of-Pocket

Combined in-and out-of-network

$4,200 per year

Inpatient Hospital Coverage¹

Per admission

$280 per day, Days 1-5, $0 Days 6 and beyond

Outpatient Surgery Services

including Ambulatory Surgical Center Services such as colonoscopies.

$250

$0

$30

$0

Emergency Room

Copayment is waived if admitted to a U.S. hospital within 24 hours.

$90

$45

$0-$15

$25

$35

Radiation Therapy¹

Per service

$60

Diagnostic Radiology Services¹

Such as MRIs, CT Scans

$125

Medicare Covered Hearing Exams

Diagnostic

$10

Medicare Covered Dental Exam

Does not include services in connection with care, treatment, filling, removal or replacement teeth.

$50

$37 monthly premium
Annual Maximum: $1,000

$50

$295 per day, Days 1-5, $0 Days 6 and beyond

$30

$0 Days 1-20, $178 per day, Days 21-49

Physical, Occupational, Speech Therapy

Includes comprehensive outpatient rehabilitation facility.

$30

$225

Not covered

20% of the cost

Covered

Chiropractic Care

Manipulation of the spine to correct when one or more of the bones in your spine move out of position.

$20

Diabetes Monitoring Supplies and Test Strips¹

One Touch™ and Accu-Chek™ All other brands are not covered

$0 for up to a 90-day supply

$0

$10

20% of the cost

$0

$0

Hearing Aid Discount
Includes a one-year warranty, three office visits, one pack of batteries and one year of loss and damage insurance. Maximum of two hearing aids per year.

Select hearing aids discounted to
$1,220-$1,985 per device.
Save $775–$1,215 per hearing aid.

Non-Medicare Covered
Eyewear Discounts offered at EyeMed providers. 

Discounts included

Included

Included

$50 per quarter

$0 for Tiers 1, 2 and 3
$260 for Tiers 4 and 5 only

30-Day Supply Preferred Pharmacy or Mail OrderPharmacy
$2 for Tier 1     $42 for Tier 3
$8 for Tier 2       $84 for Tier 4
28% of the cost for Tier 5

30-Day Supply Standard Pharmacy
$4 for Tier 1     $47 for Tier 3
$14 for Tier 2   $91 for Tier 4
28% of the cost for Tier 5

90-Day Supply Preferred Pharmacy
$5 for Tier 1       $105 for Tier 3
$20 for Tier 2     $210 for Tier 4
Tier 5 is not available

90-Day Supply Standard Pharmacy
$10 for Tier 1     $118 for Tier 3
$35 for Tier 2     $228 for Tier 4
Tier 5 is not available

31 to 90-Day Mail Order Pharmacy
$0 for Tier 1

90-Day Mail Order Pharmacy
$0 for Tier 1     $105 for Tier 3
$20 for Tier 2     $210 for Tier 4
Tier 5 is not available

You enter the coverage gap when total drug costs reach $4,020. You pay 25% and Network Health pays 75% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.

You enter catastrophic coverage when your true out-of-pocket costs reach $6,350. You pay the greater of $3.60 or 5% of the cost for generic drugs and $8.95 or 5% of the cost for brand name drugs.