| INPATIENT CARE* |
| Inpatient Hospital Care |
$0 |
$150/day (days 1-3) |
| Inpatient Mental Health Care |
$0
|
| Skilled Nursing Facility |
$0/day (days 1-20); $50/day (days 21+)
|
| Home Health Care |
$0
|
| Hospice |
$0
|
| OUTPATIENT CARE* |
| Primary Care Physician Office Visit |
$0 |
$25 |
| Specialist Office Visit (includes chiropractic and podiatry services) |
$0 |
$25 |
| Outpatient Mental Health / Substance Abuse Care |
$10/visit (visits 1-20); 45% coinsurance/visit (visits 21+)
|
| Outpatient Surgery / Surgery |
$0 |
$150/visit |
| Ambulance Services |
$25 for each one-way trip
|
| Emergency Care |
$50
($5,000 combined maximum for emergency and urgent care services outside the U.S.)
|
| Urgently Needed Care |
$10
($5,000 combined maximum for emergency and urgent care services outside the U.S.
|
| Outpatient Rehabilitation Services (includes occupational, physical and speech therapy) |
$0 (Medicare limits apply)
|
| OUTPATIENT MEDICAL SERVICES AND SUPPLIES* |
| Durable Medical Equipment |
$0 |
5% coinsurance |
| Infusion Therapy |
$0
|
| Prosthetic Devices |
$0 |
5% coinsurance |
| Diabetes Self-Monitoring Training Supplies |
$0
|
| Diagnostic Tests, X-Rays and Lab Services |
$0
|
| Visitor / Travel Benefit |
Coverage for many types of services if traveling or living outside of the service area for up to 12 months.
|
| PREVENTIVE SERVICES* |
| Bone Mass Measurement |
$0
|
| Colorectal Screening Exams |
$0 (unlimited)
|
| HIV Screenings |
$0
|
| Immunizations (pneumonia, flu and hepatitis B) |
$0 (unlimited)
|
| Mammograms |
$0 (unlimited)
|
| Pap Smears and Pelvic Exams |
$0 (unlimited)
|
| Prostate Cancer Screening Exams |
$0 (unlimited)
|
| Routine Physical Exams (one exam/year) |
$0 |
Not covered |
| PRESCRIPTION DRUG COVERAGE - Copays may vary based on member's Extra Help status* |
| Generic Prescription Drugs |
Depending on income and level of extra help or state assistance:
$0, $1.10 or $2.50
for a 30-day supply
|
| Brand-Name Prescription Drugs |
Depending on income and level of extra help or state assistance:
$0, $3.30 or $6.30
for a 30-day supply
|
| Specialty Drugs (unlimited) |
Depending on income and level of extra help or state assistance:
$0, $3.30 or $6.30
|
| ADDITIONAL BENEFITS* |
| Hearing Services (diagnostic hearing exam) |
$0 for each diagnostic exam;
Discounts on routine hearing exams and hearing aids |
$25 for each diagnostic exam;
Discounts on routine hearing exams and hearing aids |
| Vision Services |
$15 for routine eye exam; $0 for 1 pair of glasses or contacts per year |
| Health Club Membership |
$0 for health club membership
(including fitness classes)
|
| Health/Wellness Education/Services |
Nutritional training, newsletter, disease management, nurseline, smoking cessation
|
| Transportation Services |
$5/trip
(up to 48 one-way trips/year)
|
| 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
|