|
Monthly Premium
|
$16.30
|
|
Maximum Annual Out-of-Pocket Expense
|
$4,000
|
|
SERVICES / BENEFITS
|
In-Network
|
Out-of-Network
|
|
Primary Care Physician Office Visit
|
$10 |
25% |
|
Specialist Office Visit
|
$35 |
25% |
|
Annual Routine Physical Exam
|
0 -
$10 |
25% |
|
Preventive Services (mammograms,
prostate screening, cholesterol screening, pap smears, immunizations)
|
$0 |
25% |
Skilled Nursing Facility
|
$0 (days 1-9)
$50 (days 10-20)
$100 (days 21-100) |
30% |
|
Inpatient Hospitalization
|
$650/stay |
30% |
|
Outpatient Surgery / Services
|
$150 (ASC)
$0-$200 (OHF) |
25% |
|
Emergency Room
|
$50
(waived if admitted) |
$50
(waived if admitted) |
|
Urgent Care
|
$35
(waived if admitted) |
$35
(waived if admitted) |
|
Laboratory Services
|
$0 |
25% |
|
Durable Medical Equipment
|
20% |
25% |
|
Home Health Care
|
$0 |
25% |
|
Dental Services (for
Medicare-covered benefits)
|
$35 |
25% |
|
Routine Vision Exam
|
$0 |
25% |
|
Diagnostic / Treatment Vision Exam
|
$35 |
25% |
|
Routine Hearing Exam
|
$0 |
25% |
|
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.
|