|
Monthly Premium
|
$0
|
|
Maximum Annual Out-of-Pocket Expense
|
$3,000
|
|
SERVICES / BENEFITS
|
In-Network
|
|
Primary Care Physician Office Visit
|
$10
|
|
Specialist Office Visit
|
$30
|
|
Annual Routine Physical Exam
|
$0
|
|
Preventive Services (mammograms,
prostate screening, cholesterol screening, pap smears, immunizations)
|
$0
|
Skilled Nursing Facility
|
$0
(days 1-30)
|
|
Inpatient Hospitalization
|
$0
$500 (annual
out-of-pocket charge)
|
|
Outpatient Surgery / Services
|
$100
|
|
Emergency Room
|
$50
|
|
Urgent Care
|
$15
|
|
Laboratory Services
|
$0
|
|
Durable Medical Equipment
|
20%
|
|
Home Health Care
|
$0
|
|
Rehabilitation Services
(outpatient)
|
$30
|
|
Dental Services (for
Medicare-covered benefits)
|
$30
|
|
Routine Vision Exam
|
$0
|
|
Diagnostic / Treatment Vision Exam
|
$30
|
|
Routine Hearing Exam
|
$0
|
|
Prescription Drugs
Tier 1
Tier 2
Tier 3
Tier 4
|
n/a
n/a
n/a
n/a
|
|
A coordinated care plan with a Medicare Advantage contract. The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage
Members of the HMO plan must use plan providers except in emergency or urgent care situations, out-of-area renal dialysis, or prior authorized care. If you obtain routine care from out-of-network providers neither Medicare nor the Plan will be responsible for the costs.
|