iCare Family Care Partnership

• $0 copay for routine hearing exams up to 1 every year.
• $0 copay for follow-up provider visits up to unlimited per year.
• $0 copay for each Advanced level hearing aid up to 1 per ear every 3 years.
  • Note: Includes 80 batteries per aid and 3 year warranty. 
• Unlimited follow-up provider visits during first year following TruHearing hearing aid purchase.

iCare includes preventive and comprehensive dental benefits in your plan with no monthly dental premium and a $4,000 maximum coverage limit per calendar year. You must use dentists and dental specialists in the iCare dental network, DentaQuest. To find a dentist call
DentaQuest's Customer Service at 1-800-508-6758 (TTY: 711). You can also call iCare Customer Service at 1-800-777-4376 or your Care Coordinator. If you have access to the internet, you can find a dentist by using the "Find a Provider" tool on the iCare web site at www.iCareHealthPlan.org. These added benefits are included in the plan at no cost to you:

$0 Co-pay for Preventive Care
» Oral Exams — Up to three (3) per calendar year, includes emergency diagnostic exam up to one (1) per year, and
periodic oral exam up to two (2) per year.
» Prophylaxis (Cleaning): Includes periodontal maintenance up to four (4) per year and prophylaxis (cleaning) up to two (2) per year.
» Fluoride Treatment: Up to two (2) per calendar year.
» Dental X-rays include bitewing x-rays and intraoral x-rays up to one (1) set(s) per year, and panoramic film or
diagnostic x-rays up to one (1) every 5 years.

$0 Co-pay for Comprehensive Care
» Non-routine Services: Two (2) visits included every year.
» Diagnostic Services: One (1) visit included every 3 years.
» Restorative Services: Include fillings up to unlimited per year, re-cementation of crown and re-cementation of dentures up to one (1) every 5 years, crown up to one (1) per tooth per lifetime.
» Endodontics: Include root canal, root canal retreatment up to one (1) per tooth per lifetime.
» Periodontics: Include scaling and root planning (deep cleaning) up to one (1) per quadrant every 3 years, scaling for moderate inflammation up to one (1) every 3 years.
» Extractions: Surgical extractions are covered; Unlimited per year.
» Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services: Include partial dentures and complete dentures up to one (1) set(s) every 5 years, denture adjustment, denture reline, denture repair, denture rebase, tissue conditioning up to one (1) per year, occlusal adjustments up to one (1) every 3 years, oral surgery up to two (2) per year, and bridges up to one (1) every 5 years.

There may be limits on how much the plan will provide. Please contact us for more information.

There's no monthly vision premium and you can choose from an extensive network of National Vision Administrators (NVA) care providers.

Our added vision benefit provides you with these services in 2024:
» $50 combined maximum benefit coverage amount per year for routine exam.
» $400 combined maximum benefit coverage per year for contact lenses or eyeglasses (lenses and frames) and/or fitting for eyeglasses (lenses and frames).

Eyeglass lens options may be available with the maximum benefit coverage amount up to one (1) pair per year.

Maximum benefit coverage amount is limited to one time use per year.

Please refer to your iCare Medicare Plan Evidence of Coverage or EOC for more information or call your Care Coordinator. You can also call iCare Customer Service at 1-800-777-4376 (TTY: 711).

There may be limits on how much the plan will provide. Please contact us for more information.

You must use National Vision Administrators (NVA) network providers for your Medicare vision benefit. If you have a vision network question or need help finding a provider, call the NVA Customer Service Department 24/7/365 at 1-888-287-0116 (TTY: 711). You can also visit www.e-nva.com or use the “Find a Provider” search tool on the iCare website www.iCareHealthPlan.org.

$0 copay for acupuncture for chronic low back pain visits up to 20 visit(s) per year.

iCare Family Care Partnership members have the freedom to spend a $150/month allowance on the approved products and services you need with the iCare Spending Account Card!

In 2024, members have the freedom of ONE wallet on ONE card with the $150/month Healthy Options Allowance*. Watch for your Spending Account Card and OTC catalog in your mailbox. Be sure to read the information on the card carrier, including the instructions on how to activate your new card, so you'll be ready when it's time to purchase eligible items and services.

Learn more about the Healthy Options Allowance below!

*Allowance amounts cannot be combined with other benefit allowances. Limitations and restrictions may apply.

$0 RX Copay Benefit applies if you receive "Extra Help".

• You will pay the following:
• Deductible: $0
• Co-payment during the Initial Coverage Stage:

For retail and mail-order pharmacy with standard costsharing: 

• All Plan-Covered Part D Drugs: $0

$0 Rx Copay Benefit does not apply if you do not receive “Extra Help.”You will pay the following:

• Deductible: $545 except for covered insulin products and most adult Part D vaccines.
• Coinsurance during the Initial Coverage Stage:
  • All Plan-Covered Part D Drugs:
    • You pay 25% per prescription except for each covered insulin, you will pay $35 per month supply.

Cost shares apply to a 1-month and 3-month supply. Drug Tier 5 is limited to a 1-month supply.

For more information about Part D Prescription Drug coverage benefit, please see the Summary of Benefits.

As an iCare member, you have access to an online advance care planning resource called Five Wishes. This resource helps you to create an advance directive where you can combine the elements of a living will, medical power of attorney, do not attempt resuscitation, and an organ donation form.