|
Monthly Premium
|
$0
|
|
Annual Deductible
|
$400
|
|
Maximum Annual Out-of-Pocket Expense
|
$3,000
|
|
Lifetime Maximum Benefit
|
None
|
|
SERVICES / BENEFITS
|
In-Network
|
Out-of-Network
|
|
Primary Care Physician Office Visit
|
$15 |
20% |
|
Specialist Office Visit
|
$30 |
20% |
|
Annual Routine Physical Exam
|
$0 |
20% |
|
Preventive Services (mammograms,
prostate screening, cholesterol screening, pap smears, immunizations)
|
$0 |
20% |
|
Laboratory Services
|
$0 |
20% |
|
Radiology / Diagnostic Services
|
20% |
20% |
X-rays |
$0 |
20% |
|
Inpatient Hospitalization
|
$0 |
20% |
|
Outpatient Surgery / Services
|
$0 |
20% |
|
Emergency Room
|
$50 |
$50 |
|
Durable Medical Equipment
|
20% |
20% |
|
Home Health Care
|
$0 |
20% |
Skilled Nursing Facility
|
$0 |
20% |
|
Rehabilitation Services
(outpatient)
|
$30 |
20% |
|
Dental Services (for
Medicare covered benefits)
|
$30 |
20% |
|
Routine Vision & Hearing Exams
|
$0 |
20% |
|
Diagnostic / Treatment Vision Exam
|
$30 |
20% |
|
Prescription Drugs
Tier 1
Tier 2
Tier 3
Tier 4
|
$7
$35
$70
25%
|
$73
$353
$703
25%3
|
|
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
For members of the PPO plan, with the exception of emergencies or urgent care, it may cost more to get care from out-of-network providers.
|