| — Plan Health Benefits — |
| ** Base Program ** |
| Premium |
| • Wellness plan premium: $0 |
| • Drug plan premium: $0 |
| • You must proceed to pay your Part B premium. |
| • Part B premium reduction: $30 |
| Deductible |
| • Health plan deductible: $0 |
| • Other health plan deductibles: In-network: Aye |
| • Drug plan deductible: No annual deductible |
| Maximum out-of-pocket enrollee responsibleness (does non include prescription drugs) |
| • $half-dozen |
| Optional supplemental benefits |
| • No |
| Boosted benefits and/or reduced toll-sharing for enrollees with certain health conditions? |
| • In-network: Yes |
| Doctor visits |
| • Primary: $0 copay |
| • Specialist: $xxx copay per visit |
| Diagnostic procedures/lab services/imaging |
| • Diagnostic tests and procedures: $0 copay (say-so required) |
| • Lab services: $0 copay (dominance required) |
| • Diagnostic radiology services (e.g., MRI): $0-85 copay (authorization required) |
| • Outpatient 10-rays: $0-15 copay (authorization required) |
| Emergency care/Urgent care |
| • Emergency: $xc copay per visit (always covered) |
| • Urgent care: $20 copay per visit (always covered) |
| Inpatient infirmary coverage |
• $85 per day for days 1 through 10
$0 per day for days 11 through 90
$0 per day for days 91 and beyond (authorisation required) |
| Outpatient hospital coverage |
| • $0-125 copay per visit (authorization required) |
| Skilled Nursing Facility |
• $0 per day for days 1 through xx
$188 per day for days 21 through 100 (authorization required) |
| Preventive intendance |
| • $0 copay |
| Ground ambulance |
| • $265 copay |
| Rehabilitation services |
| • Occupational therapy visit: $10 copay (authorization required) |
| • Concrete therapy and oral communication and language therapy visit: $10 copay (authorization required) |
| Mental wellness services |
• Inpatient hospital - psychiatric: $85 per twenty-four hours for days ane through 10
$0 per day for days 11 through 90 (authorization required) |
| • Outpatient grouping therapy visit with a psychiatrist: $20 copay (authorisation required) |
| • Outpatient individual therapy visit with a psychiatrist: $20 copay (dominance required) |
| • Outpatient grouping therapy visit: $20 copay (authorization required) |
| • Outpatient individual therapy visit: $20 copay (authorization required) |
| Opioid treatment program services |
| • In-network: $0.00 copay |
| Medical equipment/supplies |
| • Durable medical equipment (e.m., wheelchairs, oxygen): xx% coinsurance per item (authorization required) |
| • Prosthetics (e.g., braces, bogus limbs): 20% coinsurance per item (authorization required) |
| • Diabetes supplies: 0-20% coinsurance per particular (authorization required) |
| Dialysis |
| • 20% coinsurance (dominance required) |
| Hearing |
| • Hearing examination: $20 copay |
| • Fitting/evaluation: $0 copay (limits apply) |
| • Hearing aids: $0 copay (limits utilize) |
| Preventive dental |
| • Oral examination: $0 copay (limits apply) |
| • Cleaning: $0 copay (limits use) |
| • Fluoride treatment: Not covered |
| • Dental 10-ray(due south): $0 copay (limits apply) |
| Comprehensive dental |
| • Not-routine services: Not covered |
| • Diagnostic services: $0 copay (limits utilize) |
| • Restorative services: $47-157 copay (limits apply) |
| • Endodontics: Not covered |
| • Periodontics: Not covered |
| • Extractions: $15 copay (limits apply) |
| • Prosthodontics, other oral/maxillofacial surgery, other services: $xx-217.75 copay (limits employ) |
| Vision |
| • Routine center exam: $20 copay (limits utilize) |
| • Other: Not covered |
| • Contact lenses: $0 copay (limits utilize) |
| • Eyeglasses (frames and lenses): $0 copay (limits apply) |
| • Eyeglass frames: Not covered |
| • Eyeglass lenses: Not covered |
| • Upgrades: Not covered |
| Medically-approved not-opioid pain management services |
| • Chiropractic services: Not covered |
| • Acupuncture: Non covered |
| • Therapeutic Massage: Not covered |
| • Culling Therapies: Not covered |
| More benefits |
| • Over-the-counter drug benefits: Some coverage |
| • Meals for brusk duration: Some coverage |
| • Almanac concrete exams: Some coverage |
| • Telehealth: Some coverage |
| • WorldWide emergency transportation: Some coverage |
| • WorldWide emergency coverage: Some coverage |
| • WorldWide emergency urgent care: Some coverage |
| • Fettle Benefit: Some coverage |
| • In-Abode Back up Services: Not covered |
| • Bath Safety Devices: Not covered |
| • Health Education: Some coverage |
| • In-Home Safety Cess: Not covered |
| • Personal Emergency Response System (PERS): Non covered |
| • Medical Nutrition Therapy (MNT): Non covered |
| • Post belch In-Home Medication Reconciliation: Non covered |
| • Re-admission Prevention: Not covered |
| • Wigs for Hair Loss Related to Chemotherapy: Not covered |
| • Weight Direction Programs: Not covered |
| • Adult Day Health Services: Not covered |
| • Nutritional/Dietary Do good: Not covered |
| • Habitation-Based Palliative Care: Non covered |
| • Back up for Caregivers of Enrollees: Not covered |
| • Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered |
| • Enhanced Illness Direction: Not covered |
| • Telemonitoring Services: Not covered |
| • Remote Access Technologies (including Spider web/Phone-based technologies and Nursing Hotline): Some coverage |
| • Counseling Services: Not covered |
| Wellness programs (east.m., fitness, nursing hotline) |
| • Covered |
| Transportation |
| • Non covered |
| Foot care (podiatry services) |
| • Human foot exams and treatment: $thirty copay |
| • Routine human foot care: Non covered |
| Medicare Role B drugs |
| • Chemotherapy: 20% coinsurance (authority required) |
| • Other Part B drugs: 0-20% coinsurance (authorization required) |
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