Value Plan 2017
Personal physician: $10 copay/visit
Specialist: $45 copay/visit
Days 1-7: $279 copay/day
Days 8 and beyond: $0
Days 1 - 20: $0
Days 21 - 100: $160 copay/day
Initial eye exam: $0
Eyewear: $100 for frames and lenses
Hearing exam: $45
Hearing Aids: $700-$1,050 copay/aid
Limit: 1 per ear/year
Hospital: $250 copay
Ambulatory Surgical Center: $150 copay
In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. These are three exceptions:
- The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 in the Evidence of Coverage (links to the Evidence of Coverage documents can be found above).
- If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. If your network provider suggests or recommends care out-of-network, a referral must be obtained in writing, and signed by the plan’s medical director prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider.
- Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.
Using a pharmacy that is out of the network
There are special circumstances when our plan will cover prescriptions from out of network providers/pharmacies; they are as follows:
- Drugs may be covered for an illness while members are traveling outside of the plan’s service area and where there are no network pharmacies.
- Part D vaccines administered in a clinic or hospital setting which are considered out of network.
In the event you are unable to use an in network pharmacy and none of the above scenarios would apply; you must have prior authorization (advance approval) from our plan to get prescriptions from an out-of-network pharmacy provider. If you pay out-of-pocket for a prescription and you feel we should cover this expense, please contact us or send the bill to us for payment review. You can find more detailed information regarding how this is done in your Evidence of Coverage.
Interpreter Services can be found here. We have interpreter services available to answer questions about our health and drug plan. To get an interpreter, call us at (800) 394-5566. This is a free service.
If you have questions or require language assistance, please call Customer Service at (800) 394-5566. For people who are deaf, hard of hearing, or speech impaired please call TTY/TDD 711 or toll free (800) 877-8973. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. You may also call through a video relay service company of your choice. Interpreter services are provided free of charge to you. A customer service representative is available to assist you Monday through Friday from 8 a.m. to 8 p.m. From October 1 through February 14 we are also available to assist you on Saturdays and Sundays from 8 a.m. to 8 p.m.
This web page was updated on January 24, 2018.