Plan Details
Costs and Other Important Information
Plan Year:
2018
Optional Supplemental Benefits
No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$10,000 In and Out-of-network
$5,900 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$32.50
Monthly Health Plan Premium
$34.50
Benefits
Service
Cost
Inpatient hospital coverage
In-Network:
$265 for days 1 through 6
$0 for days 7 through 90
$0 for days 91 and beyond
Out-of-Network:
40% per stay
$265 for days 1 through 6
$0 for days 7 through 90
$0 for days 91 and beyond
Out-of-Network:
40% per stay
Outpatient hospital coverage
In-Network:
$265 per visit
Out-of-Network:
40% per visit
$265 per visit
Out-of-Network:
40% per visit
Doctor visits
Primary:
In-Network:
$5 per visit
Out-of-Network:
$30-60 per visit
Specialist:
In-Network:
$35 per visit
Out-of-Network:
$60 per visit
In-Network:
$5 per visit
Out-of-Network:
$30-60 per visit
Specialist:
In-Network:
$35 per visit
Out-of-Network:
$60 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:
$10-21 or 40%
Lab services:
In-Network:
$10
Out-of-Network:
$10-21 or 40%
Diagnostic radiology services (e.g., MRI):
In-Network:
20%
Out-of-Network:
$10-21 or 40%
Outpatient x-rays:
In-Network:
$14
Out-of-Network:
$10-21 or 40%
In-Network:
20%
Out-of-Network:
$10-21 or 40%
Lab services:
In-Network:
$10
Out-of-Network:
$10-21 or 40%
Diagnostic radiology services (e.g., MRI):
In-Network:
20%
Out-of-Network:
$10-21 or 40%
Outpatient x-rays:
In-Network:
$14
Out-of-Network:
$10-21 or 40%
Mental health services
In-Network:
$265 for days 1 through 6
$0 for days 7 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
$265 for days 1 through 6
$0 for days 7 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 57
$0 for days 58 through 100
Out-of-Network:
40% per stay
$0 for days 1 through 20
$160 for days 21 through 57
$0 for days 58 through 100
Out-of-Network:
40% per stay
Rehabilitation services
Occupational therapy visit:
In-Network:
$35
Out-of-Network:
$60
Physical therapy and speech and language therapy visit:
In-Network:
$35
Out-of-Network:
$60
In-Network:
$35
Out-of-Network:
$60
Physical therapy and speech and language therapy visit:
In-Network:
$35
Out-of-Network:
$60
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:
$60
Routine foot care:
In-Network:
$35
Out-of-Network:
$60
In-Network:
$35
Out-of-Network:
$60
Routine foot care:
In-Network:
$35
Out-of-Network:
$60
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 2 (PPO)
| State | West Virginia |
|---|---|
| County | Kanawha |
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 | $12 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 | $36 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 2 (PPO) for West Virginia
/
Details
LUTHER HANSBARGER, M.D.
Phone Number
(304) 388-1552
Office Locations830 PENNSYLVANIA AVE
CHARLESTON, WV 25302
