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Silver Freedom

2022 Benefits Summary

This is a summary of what our plan covers and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please refer to the Evidence of Coverage, this legal member contract is the primary source of the coverage information and supersedes all other information.

Download the Summary of Benefits

2022 Medical Benefits
Covered Services What You Pay
Physician Services / Doctor Office Visits PCP - $0 Specialist - $20
Annual Wellness Visit $0
Telehealth Benefit PCP - $0 Specialist - $15
Preventive Health Screenings $0
Inpatient Hospital Care $325 per stay
Skilled Nursing Facility Care (SNF) $0/day - days 1-20 $125/day - days 21-100
Outpatient Diagnostic Tests and Therapeutic Services & Supplies Diagnostic labs & x-rays $0 Advanced Radiology - $150
Emergency Care $120
Ambulance Services $200
Urgently Needed Services $25
Convenient Care Per visit: $25 CVS Minute Clinics only
Over-the-Counter Items (OTC) $50 every quarter
Outpatient Hospital Observation $250
Outpatient Surgery ASC - $225 Hospital $250
Outpatient Rehab Services PT and OT - $10 Speech - $20
Outpatient Mental Health Care Individual or Group - $20
Outpatient Substance Abuse Services Individual or Group - $20
Durable Medical Equipment (DME) and Related Supplies 15-20%
Prosthetic Devices and Related Supplies 20% coinsurance
Medicare Part B Prescription Drugs 20% coinsurance (including chemotherapy)
Services to Treat Kidney Disease 20% coinsurance
Pulmonary Rehabilitation Services $20
Cardiac Rehabilitation Services $20
Chiropractic Services $20
Acupuncture $20
Podiatry Services $20
Home Health Agency Care $10
Inpatient Mental Health Care $325 per stay
Medical Nutrition Therapy $0
Dental Services $20 copayment
Preventative Dental Included
Comprehensive Dental Included
Diabetes Self Management Training, Diabetic Services and Supplies 0% - 20%
Immunizations $0
Transportation $0 - 20 one-way trips to approved medical appointments.
Smoking Cessation $0
Hearing Services $0 - $20 and $750 per ear towards the cost of hearing aid(s) every 3 years
Vision Care $0 - $20 and $125 plan allowance per year
Optional Supplemental Buy-Up Not available
Healthy Living Rewards Included
COVID-19 Benefit Acute inpatient hospital copay waived with COVID-19 diagnosis. Post hospital discharge meal delivery included.
2022 Premiums

Plan Premium

The monthly fee you pay the plan for your health care. The amount shown does not include the Part B premium you already pay to the government.

Plan Monthly Premium
Silver Freedom $0

Plan Summaries

  • Medical Coverage
  • Comprehensive Dental
  • Over-the-Counter Allowance
  • COVID-19 Coverage
  • Wellness Benefit Allowance
  • Hearing & Vision Allowances
  • No Referrals for Out-of-Network Services
  • And more

You Must:

  1. Be eligible for Medicare Part A and enrolled in Part B,
  2. Continue to pay Part B premiums,
  3. Live in the plan service area, and

How Much Does it Cost

The monthly plan premium to enroll in the Silver Freedom plan is $0. Additionally, you must maintain your Medicare Part B coverage to be a member of any Medicare Advantage plan. Most people will pay the standard Part B premium amount. Please call Social Security at 1-800-772-1213 for information about your Part B premium.

 

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