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Quick Plan Benefits
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Medicare Does Not Pay |
Medi-Pak® Plan Pays |
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A |
B |
C |
D |
F |
G |
J |
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Part A — Hospital Services |
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$1,024 Inpatient Hospital Deductible Each Benefit Period |
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$256 a Day Copayment for Days 61-90 in Hospital |
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$512 a Day Copayment for Days 91-150 in Hospital (Lifetime Reserve) |
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Percent of Medicare-Allowable Expenses (Additional 365 Days After Hospital Benefits
Stop Completely) |
100% |
100% |
100% |
100% |
100% |
100% |
100% |
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Calendar Year Blood Deductible (First 3 Pints of Blood) if the Deductible is Not Met by the Replacement of Blood |
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$128 Per Day for Days 21-100 in Skilled Nursing Facility |
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Part B — Physician and Medical Services |
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$135 Part B Deductible |
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Normally, 20% of Medicare-approved amount (Part B coinsurance) and 20% of Medicare
approved charges for durable medical equipment (after $135 Part B deductible is
met) |
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Medicare Part B Excess Charges |
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100% |
80% |
100% |
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Additional Benefits Not Covered |
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At-Home Recovery Benefits Up to $1,600 per calendar year |
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Benefits for Medically Necessary Emergency Care in a Foreign Country |
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Preventive Care — Pays up to $120 per year for an annual physical examination and preventive screening tests or services
subject to physician recommendation. |
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Vision Care from Participating Physicians (free eye exam; 15% discount on lenses,
frames and contact lenses) |
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SilverSneakers® |
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Monthly Premium — Area 1 |
$75.90 |
$92.60 |
$107.50 |
$104.50 |
$146.60 |
$101.20 |
$117.20 |
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Monthly Premium — Area 2 |
$85.80 |
$104.60 |
$121.70 |
$118.20 |
$146.60 |
$101.20 |
$132.50 |
Area 1 Counties:
Arkansas, Ashley, Baxter, Benton, Boone, Bradley, Calhoun, Carroll, Chicot, Clay,
Cleveland, Columbia, Craighead, Crawford, Crittenden, Desha, Drew, Franklin, Fulton,
Grant, Greene, Jefferson, Johnson, Lafayette, Lee, Lincoln, Logan, Madison, Marion,
Miller, Mississippi, Monroe, Montgomery, Newton, Phillips, Poinsett, Polk, Pope,
Prairie, Randolph, Scott, Searcy, Sebastian, St. Francis, Stone, Union, Washington,
White, Woodruff and Yell.
Area 2 Counties:
Clark, Cleburne, Conway, Cross, Dallas, Faulkner, Garland, Hempstead, Hot Spring,
Howard, Independence, Izard, Jackson, Lawrence, Little River, Lonoke, Nevada, Ouachita,
Perry, Pike, Pulaski, Saline, Sevier, Sharp and Van Buren.
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