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† Supplemental benefits shown are in-network and administered by VSP. There are a number of options to receive frames and basic lenses within this benefit amount.
‡ This is the 2024 amount, and may change for 2025.
⅄ You must use a dentist who is part of Delta Dental of Washington’s dental network. To find the most current listing of Delta Dental PPO Plus Premier network dentists, visit DeltaDentalWA.com.
# Exact amount depends on level of Extra Help.
* All cost-sharing on this plan, including premiums, medical, and prescription drug costs, is based upon your level of Medicaid eligibility. If you are enrolled with the State or another plan for Medicaid benefits, Community Health Plan of Washington Medicare Advantage will help you resolve any billing issues. Your doctor cannot bill you for cost-sharing covered under your Medicaid benefits. Your doctor must accept Community Health Plan of Washington Medicare Advantage plan payment as payment-in-full or bill the correct Medicaid source. Part B deductible reflects amount that would apply without full Medicaid cost-sharing assistance.

** Your monthly plan premium of $26.20 is paid for as long as you qualify for 100% Low Income Subsidy (“Extra Help”). For more information on Extra Help, see Chapter 1, section 4, of your Evidence of Coverage. You must continue to pay your Medicare Part B premium (unless your Part B premium is paid for you by Washington State Medicaid or another third party).

*** Health and Wellbeing is $0 copay for 12 visits/year combined for acupuncture, naturopathy, and routine chiropractic for Plans 4 and Freedom Plan. Dual Complete Plan, Dual Select Plan, and Plan 2 cover a combined 25 visits of acupuncture, naturopathy, routine chiropractic, and massage therapy.