| INPATIENT CARE* |
| Inpatient Hospital Care |
$50/day (days 1-10)
|
Medicare-level deductible, coinsurance and copayment |
| Inpatient Mental Health Care |
$50/day (days 1-10)
|
Medicare-level deductible, coinsurance and copayment |
| Skilled Nursing Facility |
$0/day (days 1-20);
$50/day (days 21+)
|
20% |
| Home Health Care |
$0
|
20% |
| OUTPATIENT CARE* |
| PCP Office Visit |
$5 |
$25 |
20% |
| Specialist Office Visit (includes chiropractic and podiatry services) |
$15 |
$25 |
20% |
| Outpatient Mental Health / Substance Abuse Care |
$15/visit (visits 1-20)
45% coinsurance/visit (visits 21+)
|
20% |
| Outpatient Surgery |
$50 |
$150 |
20% |
Emergency Care
(Waived if admitted to inpatient hospital care) |
$50
($5,000 annual combined maximum for urgently needed and emergency care outside the U.S.)
|
| Ambulance Service |
$100 for each one-way trip
|
Urgently Needed Care
(within U.S.) |
$25
|
| Urgently Needed Care (outside of U.S.) |
$50
($5,000 annual combined maximum for urgently needed and emergency care outside the U.S.)
|
| Outpatient Rehabilitation Services (includes occupational, physical and speech therapy) |
$10 (Medicare limits apply) |
$10 (Medicare limits apply) |
20% (Medicare limits apply) |
| OUTPATIENT MEDICAL SERVICES AND SUPPLIES* |
| Durable Medical Equipment |
20%
|
| Infusion Therapy |
$0
|
20% |
| Prosthetic Devices |
20%
|
| Diabetes Self-Monitoring Training and Supplies |
$0 |
$0 |
20% |
| Diagnostic Tests, X-Rays and Lab Services |
$0 |
$0 |
20% |
| PREVENTIVE SERVICES* |
| Bone Mass Measurement |
$0 |
$0 |
20% |
| Colorectal Screening Exams |
$0 (1st exam), $5 for additional exams; unlimited |
$0 (1st exam), $5 for additional exams; unlimited |
20% |
| HIV Screenings |
$0 |
$0 |
$0 |
Immunizations
(Flu and pneumonia) |
$0
|
| Mammograms |
$0 (1st exam),
$5 for additional exams; unlimited |
$0 (1st exam),
$5 for additional exams; unlimited |
20% |
| Pap Smears and Pelvic Exams |
$0 (1st exam),
$5 for additional exams; unlimited |
$0 (1st exam),
$5 for additional exams; unlimited |
20% |
| Prostate Cancer Screening Exams |
$0 (1st exam),
$5 for additional exams; unlimited |
$0 (1st exam),
$5 for additional exams; unlimited |
20% |
Routine Physical Exams
(one exam/year) |
$5 |
Not covered |
Not covered |
| TRANSPORTATION* |
| Transportation |
$5/trip up to 12 one-way trips/year
|
Not covered |
| ADDITIONAL BENEFITS* |
| Dental Services |
$0 for selected preventive dental services, including oral exam, cleaning, dental X-rays
(Annual max. of $1,000 applies)
$50 deductible for comprehensive services
|
Hearing Services
(Diagnostic hearing exam) |
$15
for each diagnostic hearing exam;
Discounts on routine hearing exams and hearing aids
|
$25
for each diagnostic hearing exam;
Discounts on routine hearing exams and hearing aids
|
20%
for each diagnostic hearing exam;
Discounts on routine hearing exams and hearing aids
|
| Vision Services |
$15 for routine exam (1 per year); $0 for 1 pair of glasses or contact lenses per year
|
Routine eye exams and eyewear not covered |
| Health Club Membership |
$0 for health club membership (including fitness classes)
|
Not covered |
| Health/Wellness Education/Services |
Nutritional training, smoking cessation, newsletter, disease management, nurseline
|
Not covered |
| PRESCRIPTION DRUG COVERAGE (PART D) |
| Generic Drugs |
$5 for a 30-day supply
|
| Preferred Brand-Name Drugs |
$30 for a 30-day supply
(Not covered in the gap)
|
| Non-Preferred Brand-Name Drugs |
$50 for a 30-day supply
(Not covered in the gap)
|
| Specialty Drugs |
20% coinsurance for a 30-day supply
(Not covered in the gap)
|
| Mail-order Prescription Drugs (up to a 90-day supply) |
Three copays for 90 day supply
|