Medicare Advantage Plan Costs - January 1, 2018

Retiree Share of Monthly Premium

  Senior Blue 699 HMO CDPHP Choices PPO MVP Gold PPO
Retiree Only Coverage Cost $179.00 $147.35 $205.30
Retiree Plus Spouse Coverage Cost $358.00 $294.70 $410.60

In Network Plan Co-Payment Comparison**

**This comparison is a brief overview of the most frequently asked about in-network co-payments under the offered health plans, provided as a courtesy to retirees. It is NOT, nor is it intended to be, a full summary of all services/co-pays available under each plan. Please refer to the individual plan documents and benefit summaries for a complete listing of all services and associated out of pocket costs.

In Network Senior Blue 699 HMO CDPHP Choices PPO MVP Gold PPO
Doctor/Specialist Co-Pay $10/$25 $10/$15 $10/$15
Drug Co-Pay Tiers 1-5 $0/$10/$25/$50/$50 Preferred Pharmacies $0/$5/$20/$35/$35 $0/$5/$15/$30/$30/$0
Inpatient Hospitalization Co-Pay $250 $0 $0
Emergency Room Co-Pay* $50 $75 $65
Ambulance Co-Pay $75 $100 $35
Laboratory Testing $10 $15** $0
X-Rays $25 $15 $15
Urgent Care $50 $25 $15
Annual Dental Allowance $75 $250 $300
Annual Vision Allowance $75 $100 $100

*The Emergency Room Co-Payment listed above is waived on all plans if you are admitted inpatient to the hospital

**Only the Laboratory Testing Co-payments listed above for the CDPHP plan are waived if the provider is preferred. The CDPHP dental allowance of $250 is for the following services: 2 cleanings and 2 exams per year, and fluoride application and x-rays once per benefit year

Highlighted areas above are co-pay changes for 2018. Please refer to the complete plan documents for any additional co-payment changes.