Plan Details
Costs and Other Important Information
Plan Year:
2018
Optional Supplemental Benefits
Yes
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$5,100 In and Out-of-network
$2,900 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$22.70
Monthly Health Plan Premium
$54.30
Benefits
Service
Cost
Inpatient hospital coverage
In-Network:
$275 for days 1 through 5
$0 for days 6 through 90
$0 for days 91 and beyond
Out-of-Network:
40% per stay
$275 for days 1 through 5
$0 for days 6 through 90
$0 for days 91 and beyond
Out-of-Network:
40% per stay
Outpatient hospital coverage
In-Network:
$275 per visit
Out-of-Network:
40% per visit
$275 per visit
Out-of-Network:
40% per visit
Doctor visits
Primary:
In-Network:
$0 copay
Out-of-Network:
$35-50 per visit
Specialist:
In-Network:
$35 per visit
Out-of-Network:
$50 per visit
In-Network:
$0 copay
Out-of-Network:
$35-50 per visit
Specialist:
In-Network:
$35 per visit
Out-of-Network:
$50 per visit
Preventive care
In-Network:
$0 copay
Out-of-Network:
0-40%
$0 copay
Out-of-Network:
0-40%
Emergency care/Urgent care
Emergency:
$80 per visit (always covered)
Urgent care:
$30-40 per visit (always covered)
$80 per visit (always covered)
Urgent care:
$30-40 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
In-Network:
20%
Out-of-Network:
40%
Lab services:
In-Network:
$0
Out-of-Network:
$0 copay
Diagnostic radiology services (e.g., MRI):
In-Network:
20%
Out-of-Network:
40%
Outpatient x-rays:
In-Network:
$14
Out-of-Network:
$21
In-Network:
20%
Out-of-Network:
40%
Lab services:
In-Network:
$0
Out-of-Network:
$0 copay
Diagnostic radiology services (e.g., MRI):
In-Network:
20%
Out-of-Network:
40%
Outpatient x-rays:
In-Network:
$14
Out-of-Network:
$21
Mental health services
In-Network:
$275 for days 1 through 5
$0 for days 6 through 90
Out-of-Network:
40% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:
$30
Out-of-Network:
$35-45
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
$35-45
Outpatient group therapy visit:
In-Network:
$30
Out-of-Network:
$35-45
Outpatient individual therapy visit:
In-Network:
$40
Out-of-Network:
$35-45
$275 for days 1 through 5
$0 for days 6 through 90
Out-of-Network:
40% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:
$30
Out-of-Network:
$35-45
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
$35-45
Outpatient group therapy visit:
In-Network:
$30
Out-of-Network:
$35-45
Outpatient individual therapy visit:
In-Network:
$40
Out-of-Network:
$35-45
Skilled Nursing Facility
In-Network:
$0 for days 1 through 20
$160 for days 21 through 39
$0 for days 40 through 100
Out-of-Network:
40% per stay
$0 for days 1 through 20
$160 for days 21 through 39
$0 for days 40 through 100
Out-of-Network:
40% per stay
Rehabilitation services
Occupational therapy visit:
In-Network:
$35
Out-of-Network:
$50
Physical therapy and speech and language therapy visit:
In-Network:
$35
Out-of-Network:
$50
In-Network:
$35
Out-of-Network:
$50
Physical therapy and speech and language therapy visit:
In-Network:
$35
Out-of-Network:
$50
Ambulance
In-Network:
$250
Out-of-Network:
$250
$250
Out-of-Network:
$250
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:
In-Network:
$35
Out-of-Network:
$50
Routine foot care:
In-Network:
$35
Out-of-Network:
$50
In-Network:
$35
Out-of-Network:
$50
Routine foot care:
In-Network:
$35
Out-of-Network:
$50
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network:
20% per item
Out-of-Network:
50% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
40% per item
Diabetes supplies:
In-Network:
$0 per item
Out-of-Network:
40% per item
In-Network:
20% per item
Out-of-Network:
50% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
40% per item
Diabetes supplies:
In-Network:
$0 per item
Out-of-Network:
40% per item
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
In-Network:
20%
Out-of-Network:
40%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
40%
In-Network:
20%
Out-of-Network:
40%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
40%
Coverage Area for AARP MedicareComplete Choice (PPO)
| State | Illinois |
|---|---|
| County | Cook |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
| 30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | Not offereds | $3 copay | Not offered |
| Tier 2: Non-Preferred Generic | Not offered | $10 copay | Not offered |
| Tier 3: Preferred Brand Name | Not offered | $45 copay | Not offered |
| Tier 4: Non-Preferred Brand Name | Not offered | $95 copay | Not offered |
| Tier 5: Specialty Tier | Not offered | 33% coinsurance | Not offered |
| 90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | Not offered | $9 copay | $0 copay |
| Tier 2: Non-Preferred Generic | Not offered | $30 copay | $0 copay |
| Tier 3: Preferred Brand Name | Not offered | $135 copay | $125 copay |
| Tier 4: Non-Preferred Brand Name | Not offered | $285 copay | $275 copay |
| Tier 5: Specialty Tier | Not offered | 33% coinsurance | 33% coinsurance |
Physician Finder
Physicians that accept AARP MedicareComplete Choice (PPO) for Illinois
/
Details
VENKATA VEDAM, M.D.
Phone Number
(773) 884-7930
Office Locations2701 W 68TH ST
CHICAGO, IL 60629
