MEDICARE

COUNTIES COVERED

ALL

RIVERSIDE

SAN BERNARDINO

RIVERSIDE

SAN BERNARDINO

MONTHLY PREMIUM

Part B            $  54.00

$25

(plus $54 for Medicare Part B)

$0

(plus $54 for Medicare Part B)

OFFICE VISIT

$100 annual  deductible.               20% co pay on approved Medicare charges

$10

$10

HOSPITALIZATION

1-60 days     $812.00

61-90 days   $203.00 a day

91-150 days $406.00 a day

$100 a day for 1-5 days. $0 for days 6-90 for a Medicare-covered stay.  A maximum $500 out of pocket limit for every  stay.

$125 a day for 1-90 days on Medicare- covered stay.  Unlimited days each ben. period. A maximum of $2,000 out of pocket annually.

PRESCRIPTION DRUGS

Co-Payment and Cap

NOT COVERED

Formulary/Non Form. Generic: $10/30-day sup. Form. Brand $25/30 day sup. Non Form. Brand $50/30 day sup.  Mail order avail.  $1,000 limit for combined Formulary

Brand, Form. Generic & Non Form.  Brand

Formulary Generic $8/30 day sup. Formulary mail in $20/90 day sup. No limit on Form. Generic.  Not covered for drugs NOT on a plan approved list (formulary).

SKILLED NURSING

(Facility Co-Payment

Medicare criteria applies)

3 days prior hospital.

1- 20 days - $0

21-100 day- $101.50 per day

Over 100 days, benefit period not covered.

$0 up to 100 days per benefit period.  No prior hospital stay required.

$0 up to 100 days per benefit period. No hospital stay is required.

AMBULANCE

20% co-pay on Medicare approved amounts or applicable fee schedule

$100 for Medicare-covered ambulance services.

$250 for Medicare-covered ambulance services.

CHIROPRACTIC CARE

20% co pay,  $100 deductible

applies to all  Part B benefits

$15 for each Medicare-covered visit.

$10 for each Medicare-covered visit.

DENTAL CARE

NOT COVERED

NOT COVERED

$0 office visit includes: exams, x-rays.  $30-40 for cleaning up to 2 visits.  Additional benefits available.

EMERGENCY ROOM         

20% co pay, $100 deductible

Worldwide not covered

$50  for each Medicare-covered emergency rm visit. Waived  if  admitted to hospital.  Worldwide coverage

$50 for each Medicare-covered emergency room visit.  Worldwide coverage.

HEARING CARE

NOT COVERED

  $15 each Medicare-covered diagnostic exam.  $0-$10 for each routine test; 1 test per year. Hearing aids not covered.                     

$10 for each Medicare-covered diagnostic exam.  $10 for each routine test, 1 test per year. Hearing aids not covered.

HOME HEALTH CARE

 $0  co pay for Medicare- covered home health visits

No co-payment for Medicare-covered home health visits

$0 co pay for Medicare-covered home health visits

MENTAL HEALTH CARE   (Outpatient)

50% co pay, $100 deductible applies to all Part B benefits

$25 for Medicare-covered mental health services.

$20 for Medicare-covered mental health services.

PODIATRY CARE

20% co pay on approved Medicare amounts.  $100 deductible applies to all  Part B benefits

$15 for each Medicare-covered visit (medically necessary foot care).

$10 for each Medicare-covered visit (medically necessary foot care).

VISION CARE

        NOT COVERED

Except for eye disease

      exams

$15 for each Medicare-covered eye exam (diagnostic/treatment).  $15 for each routine eye exam once a yr.

$10 for Medicare-covered eye exam (diagnostic/ treatment) $10-$20 ea routine exam. $75 -1 pr of glasses every 2 yrs.

URGENT CARE

OUT OF SERVICE AREA

20% co pay,  100% deductible

Not covered outside the U.S. except under limited circumstances

$50 for each Medicare covered urgently needed care visit.  Worldwide coverage.

$50 for each Medicare covered urgently needed care visit. Waived if admitted to hospital within 24 hrs.  Worldwide coverage.

PREVENTIVE SERVICES*

NOT COVERED

Except for specified service.

$10 for routine physical exam.

 Limit 1 exam per year.

$10 for routine physical exam.

 No limit per year.