|
Monthly Premium
|
$0
|
|
Maximum Out-of-Pocket Expense
|
$4,800
|
|
SERVICES / BENEFITS
|
In-Network
|
Out-of-Network
|
|
Primary Care Physician Office Visit
|
$10
|
30%
|
|
Specialist Office Visit
|
$35
|
30%
|
|
Annual Routine Physical Exam
|
$0
|
30%
|
|
Preventive Services (mammograms,
prostate screening, cholesterol screening, pap smears, immunizations)
|
$0
|
30%
|
|
Diagnostic Radiology Services
|
20%
|
30%
|
|
X-Ray
|
$0
|
30%
|
|
Inpatient Hospitalization
|
$220/day
(days 1-8)
|
30%
|
|
Urgent Care Center
|
$25 (waived if admitted)
|
$25 (waived if admitted)
|
|
Emergency Room
|
$50 (waived if admitted)
|
$50 (waived if admitted)
|
|
Laboratory Services
|
$0
|
30%
|
|
Durable Medical Equipment
|
20%
|
30%
|
|
Home Health Care
|
$0
|
30%
|
|
Dental Services (oral exams,
cleanings, dental x-rays)
|
$0 preventive
$35 Medicare-covered benefits
|
$0 preventive
30% comprehensive benefits
|
|
Routine Vision Exam
|
$35
|
30%
|
|
Hearing Exam (annual)
|
$35
|
30%
|
|
Prescription Drugs
Tier 1
Tier 2
Tier 3
Tier 4
|
$7
$35
$70
33%
|
$7
$35
$70
33%
OON Coverage for Pharmacy
|
|
Medicare beneficiaries may enroll
in Mercy MedicareADVANTAGE through the CMS Medicare Online
Enrollment Center located at
http://www.medicare.gov.
|
|
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.
|