Summary of Benefits

Monthly Premium, Deductibles, and Coverage Limits

Monthly Premium, Deductibles, and Coverage Limits
	MDwise Medicare Inspire (HMO)	MDwise Medicare Inspire Plus (HMO)	MDwise Medicare Inspire Flex (HMO-POS)
Your Monthly Plan Premium (in addition to your Medicare Part B premium)	You pay $0	You pay $25	You pay $49
Deductible	Medical Services $300 Prescription Drug Tiers 3 – 5: $100	Medical Services $0 Prescription Drug $0	Medical Services $100 in-network only Prescription Drug $0
Maximum Out-of-Pocket Responsibility This is the most you will pay for copays, coinsurance, and other costs for medical services for the year.	$5,200 for in-network Medicare-covered benefits	$4,300 for in-network Medicare-covered benefits	$4,300 for in-network Medicare-covered benefits

Covered Medical Benefits

Medical Benefits

MDwise Medicare Inspire (HMO)

MDwise Medicare Inspire Plus (HMO)

MDwise Medicare Inspire Flex (HMO-POS)

Inpatient Hospital Coverage

We cover an unlimited number of days for an inpatient hospital stay.

Prior authorization may be

required.

$295 copay per day for days 1 through 7

You pay nothing per day for days 8 through 90

You pay nothing per day for days 91 and beyond

$290 copay per day for days 1 through 7

You pay nothing per day for days 8 through 90

You pay nothing per day for days 91 and beyond

In-network

$310 copay per day for days 1 through 7

You pay nothing per day for days 8 through 90

You pay nothing per day for days 91 and beyond

Point-of-service

30% of the cost/stay

Outpatient Hospital Coverage

Prior authorization and referral may be required.

Outpatient Hospital:

$275 copay for each visit

Ambulatory Surgical Center: $250 copay for each visit

Observation:

$275 copay for each visit

Outpatient Hospital:

$275 copay for each visit

Ambulatory Surgical Center: $250 copay for each visit

Observation:

$275 copay for each visit

In-network Outpatient Hospital:

$275 copay for each visit

Ambulatory Surgical Center: $250 copay for each visit

Observation:

$275 copay for each visit

Point-of-service

30% of the cost

Doctor Visits

Specialist visits require a

referral.

Primary Care:

$5 copay per visit

Specialist:

You pay a $40 copay per visit

Primary Care:

$0 copay per visit

Specialist:

You pay a $40 copay per visit

In-network Primary Care:

$0 copay per visit

Specialist:

You pay a $40 copay per visit

Point-of-service

30% of the cost

Preventive Care

You pay nothing

In-network

You pay nothing

Point-of-service

30% of the cost

Emergency Care

Your copay will be waived if you are admitted directly into the hospital.

You pay a $90 copay per visit in or out of network

Urgently Needed Services

You pay a $40 copay per visit in or out

of network

You pay a $40 copay per visit in or out

of network

You pay a $40 copay per visit in or out of

network

Outpatient Diagnostic Services/Labs/ Imaging

Prior authorization and referral may be required. Outpatient X-rays do not require prior authorization or referral.

Diagnostic radiology service (CT/MRI):

$200 copay

Lab services: $0 copay

Diagnostic tests and procedures:

$50 copay

Outpatient X-rays:

$25 copay

Diagnostic radiology service (CT/MRI):

$150 copay

Lab services: $0 copay

Diagnostic tests and procedures:

$30 copay

Outpatient X-rays:

$25 copay

In-network Diagnostic radiology service (CT/MRI):

$150 copay

Lab services: $0 copay

Diagnostic tests and procedures:

$30 copay

Outpatient X-rays:

$25 copay

Point-of-service

30% of the cost

Hearing Services

Hearing exams: You pay a $40 copay for a Medicare-covered

hearing exam

You pay a $10 copay for non-Medicare covered routine hearing exams

Hearing aids: You pay a $10 for one hearing aid fitting and evaluation per year.

You will be reimbursed for up to $750 per year for hearing aids.

Hearing exams: You pay a $30 copay for a Medicare-covered

hearing exam

You pay a $0 copay for non-Medicare covered routine hearing exams

Hearing aids: You pay a $0 for one hearing aid fitting and evaluation per year.

You will be reimbursed for up to $1500 per year for hearing aids.

In-network Hearing exams:

You pay a $30 copay for a Medicare-covered hearing exam

You pay a $0 copay for non-Medicare covered routine hearing exams

Point-of-service

30% of the cost

Hearing aids: You pay a $0 for one hearing aid fitting and evaluation per year.

You will be reimbursed for up to $1500 per year for hearing aids.

Dental Services

In-network preventive dental services are provided by Delta Dental’s Medicare Advantage PPO and Premier network dentists.

Oral exam and cleaning: $0 copay for two exams and two cleanings each year

Filings and crown repair: 50% coinsurance

Fluoride treatment: $0 copay for one treatment each year

Bitewing X-rays: $0 copay for one set each year

Full mouth X-rays: $0 copay once every 5 years

Vision Services

Medicare-covered services:

$40 copay for each visit

$0 copay for eyeglasses or contact lenses after cataract surgery

$0 copay for glaucoma screening

Routine vision services:

$0 copay for a routine eye exam

$0 copay for non- Medicare-covered routine corrective eyeglasses (lenses and frames) or contact lenses.

You will be reimbursed up to a maximum of

$100 each year.

Medicare-covered services:

$30 copay for each visit

$0 copay for eyeglasses or contact lenses after cataract surgery

$0 copay for glaucoma screening

Routine vision services:

$0 copay for a routine eye exam

$0 copay for non- Medicare-covered routine corrective eyeglasses (lenses and frames) or contact lenses.

You will be reimbursed up to a maximum of

$200 each year.

In-network Medicare-covered services:

$30 copay for each visit

$0 copay for eyeglasses or contact lenses after cataract surgery

$0 copay for glaucoma screening

Point-of-service

30% of the cost

Routine vision services:

$0 copay for a routine eye exam

$0 copay for non- Medicare-covered routine corrective eyeglasses (lenses and frames) or contact lenses.

You will be reimbursed up to a maximum of

$200 each year.

Mental Health Services

Our plan covers up to 190 days in a lifetime for inpatient care in a psychiatric hospital. Our

plan covers 90 days for an

inpatient hospital stay.

Prior authorization may be required for inpatient mental health services.

Inpatient:

$265 copay per day for days 1 through 7

You pay nothing per day for days 8 through 90

Outpatient therapy (group or individual):

$30 copay per session

Inpatient:

$265 copay per day for days 1 through 7

You pay nothing per day for days 8 through 90

Outpatient therapy (group or individual):

$25 copay per session

In-network Inpatient:

$265 copay per day for days 1 through 7

You pay nothing per day for days 8 through 90

Outpatient therapy (group or individual):

$25 copay per session

Point-of-service

30% of the cost

Skilled Nursing Facility (SNF)

Our plan covers up to 100 days each benefit period in a SNF. A benefit period starts the day you go into a SNF and ends when

you go 60 days in a row

without SNF care.

Prior authorization may be

required.

You pay nothing per day for days 1 through 20

$188 copay per day for days 21 through 100

You pay nothing per day for days 1 through 20

$188 copay per day for days 21 through 100

In-network

You pay nothing per day for days 1 through 20

$188 copay per day for days 21 through 100

Point-of-service

30% of the cost

Physical Therapy

Prior authorization and

referral may be required.

$40 copay per visit

In-network

$40 copay per visit

Point-of-service

30% of the cost

Ambulance

Prior authorization may be required for Medicare covered non-emergency transport.

$250 copay per one-way transport

$250 copay per one-way transport in or

out of network

Transportation

Prior authorization and

referral may be required.

Not covered

Not Covered

Not covered

Medicare Part B Drugs

Prior authorization may be required

Chemotherapy and Other Part B Drugs: 20% of the cost

Home Infusion Drugs:

$0 copay

Chemotherapy and Other Part B Drugs: 20% of the cost

Home Infusion Drugs:

$0 copay

In-network Chemotherapy and Other Part B Drugs: 20% of the cost

Home Infusion Drugs: $0 copay

Point-of-service

30% of the cost

Prescription Drug Benefits

Prescription Drug Benefits
Stage	MDwise Medicare Inspire (HMO)		MDwise Medicare Inspire Plus (HMO)		MDwise Medicare Inspire Flex (HMO-POS)
Stage 1: Deductible Stage For plans with a deductible, you start here when you fill your first prescription of the year.	You pay the full cost for drugs in tiers 3-5 until your out-of-pocket costs reach $100. Once you pay $100 for drugs in tiers 3 – 5 you will move to the Initial Coverage Stage During this stage, your out-of-pocket costs for a 30-day supply of Select Insulins will be $10-$35.		$0 Because you have no deductible, you will start in the Initial Coverage Stage when you fill your first prescription of the year.		$0 Because you have no deductible, you will start in the Initial Coverage Stage when you fill your first prescription of the year.
Stage 2: Initial Coverage Stage Once you have paid your deductible, if applicable, you will pay the following copays/ coinsurance until your total drug cost (what you pay plus what we pay) reaches $4,430.	Retail Pharmacy (30-day supply)	Mail-Order Pharmacy (90-day supply)	Retail Pharmacy (30-day supply)	Mail- Order Pharmacy (90-day supply)	Retail Pharmacy (30-day supply)	Mail-Order Pharmacy (90-day supply)
Tier 1: Preferred Generic	$3.50	$7.88	$3.50	$7.88	$3.50	$7.88
Tier 2: Generic	$12.50 Select Insulins: $10	$28.13 Select Insulins: $22	$12.50 Select Insulins: $10	$28.13 Select Insulins: $22	$12.50 Select Insulins: $10	$28.13 Select Insulins: $22
Tier 3: Preferred Brand	$47 Select Insulins: $35	$105.75 Select Insulins: $78	$47 Select Insulins: $35	$105.75 Select Insulins: $78	$47 Select Insulins: $35	$105.75 Select Insulins: $78
Tier 4: Non-Preferred Brand	$100	$225	$100	$225	$100	$225
Tier 5: Specialty Tier	31%	N/A	33%	N/A	33%	N/A
Tier 6: Select Care Drugs	$0	N/A	$0	N/A	$0	N/A
Stage 3: Coverage Gap Stage	During this stage, you continue to pay your copay for drugs on Tier 1. Your out- of-pocket costs for Select Insulins will be $10-$35. For all other generics, you pay 25% of the price. For brand name drugs, you pay 25% of the price (plus a portion of the dispensing fee). You will remain in this stage until your out-of-pocket costs reach $7,050
Stage 4: Catastrophic Coverage Stage	In this stage, your share of the cost for a covered drug will be either coinsurance or a copayment, whichever is the larger amount: either – coinsurance of 5% of the cost of the drug $3.95 for a generic drug or a drug that is treated like a generic and $9.85 for all other drugs. Our plan pays the rest of the cost.

Optional Supplemental Dental Benefits

	Delta Dental Option 1	Delta Dental Option 2
Premium Optional dental premium	$23 per month	$34 per month
must be paid in addition to your Medicare Part B and monthly premiums.
Deductible
	$0	$0
Services	Major restorative services, bridges, dentures, and implant services: 75% coinsurance	Major restorative services, bridges, dentures, and implant services: 50% coinsurance
	Endodontics, periodontics, bridge and denture repair, simple extractions, oral surgery, and films, anesthesia & tests: 50% coinsurance	Endodontics, periodontics, bridge and denture repair, simple extractions, oral surgery, and films, anesthesia & tests: 20% coinsurance
Maximum Benefit	You will be covered for $1,000 of	You will be covered for $1,500 of
Limit	dental services per year. Once you reach this limit, you will have to pay all costs for dental services.	dental services per year. Once you reach this limit, you will have to pay all costs for dental services.

Additional Covered Medical Benefits

Medical Benefits	MDwise Medicare Inspire (HMO)	MDwise Medicare Inspire Plus (HMO)	MDwise Medicare Inspire Flex (HMO-POS)
Acupuncture Medicare-covered acupuncture for chronic lower back pain	You pay a $25 copay per visit	You pay a $25 copay per visit	In-network You pay a $25 copay per visit Point-of-service Not covered out-of-network
Annual Physical Exam Comprehensive preventive medical evaluation	You pay nothing	You pay nothing	In-network You pay nothing Point-of-service 30% of the cost
Chiropractic care	You pay a $20 copay per visit	You pay a $20 copay per visit	In-network You pay a $20 copay per visit Point-of-service 30% of the cost
Durable medical equipment Prior authorization may be required	You pay a 20% coinsurance	You pay a 20% coinsurance	In-network You pay a 20% coinsurance Point-of-service 30% of the cost
Enhanced disease management Prior authorization and referral may be required	If you have a chronic conditions you may qualify for one of our enhanced disease management programs. These special educational programs promote a deep understanding of the disease process and provide individual teaching and coaching to help you have a healthier lifestyle. A care manager is available to those who qualify for these customized programs. You pay nothing for enhanced disease management
Fitness membership	Our plan will reimburse you for up to a maximum of $100 for your fitness center membership	Our plan will reimburse you for up to a maximum of $200 for your fitness center membership	Our plan will reimburse you for up to a maximum of $200 for your fitness center membership
Meals after discharge Prior authorization and referral may be required	Not covered	Benefit covers 28 meals (2 meals per day for 14 days) delivered directly to your home after each discharge from an inpatient acute or a skilled nursing facility stay. Annual limit of 5 discharges for a total of 140 meals per year.	Benefit covers 28 meals (2 meals per day for 14 days) delivered directly to your home after each discharge from an inpatient acute or a skilled nursing facility stay. Annual limit of 5 discharges for a total of 140 meals per year.
Nutritional/dietary benefit Prior authorization may be required	We cover 6 counseling sessions through a registered dietician or other nutrition professional. We want to help you improve your health and lifestyle by providing tools so you make healthy choices. Talk to your physician to see if you would benefit from nutrition counseling. You pay nothing for these sessions
Over-the-counter items	You are eligible for a $50 quarterly benefit to be used toward the purchase of over- the-counter (OTC) health and wellness products that do not need a prescription.
Prosthetic devices and related medical supplies	You pay a 20% coinsurance	You pay a 20% coinsurance	In-network You pay a 20% coinsurance Point-of-service 30% of the cost
Worldwide emergency care	Not covered	You may receive covered emergency and urgent care services anywhere in the world. If you are outside of the United States or its territories, your worldwide emergency and urgent care coverage is limited to $50,000 per year. All costs over $50,000 for worldwide emergency and urgent care services are your responsibility. You pay a $90 copay per visit.
Worldwide urgently needed services	Not covered	You may receive covered emergency and urgent care services anywhere in the world. If you are outside of the United States or its territories, your worldwide emergency and urgent care coverage is limited to $50,000 per year. All costs over $50,000 for worldwide emergency and urgent care services are your responsibility. You pay a $40 copay per visit.

MDwise Medicare
Summary of Benefits

2022 Summary of Benefits

Monthly Premium, Deductibles, and Coverage Limits

Covered Medical Benefits

Prescription Drug Benefits

Optional Supplemental Dental Benefits

Additional Covered Medical Benefits

MDwise Medicare Summary of Benefits

2022 Summary of Benefits

Monthly Premium, Deductibles, and Coverage Limits

Covered Medical Benefits

Prescription Drug Benefits

Optional Supplemental Dental Benefits

Additional Covered Medical Benefits

MDwise Medicare
Summary of Benefits