| INPATIENT CARE* |
| Inpatient Hospital Care |
$50/day (days 1-10)
|
| Inpatient Mental Health Care |
$50/day (days 1-10)
|
| Skilled Nursing Facility |
$0/day (days 1-20)
$50/day (days 21+)
|
| Home Health Care |
$0
|
| Hospice |
$0
|
| OUTPATIENT CARE* |
| PCP Office Visit |
$5 |
$25 |
Specialist Office Visit:
(includes chiropractic and podiatry services) |
$15 |
$25 |
Outpatient Behavioral/
Substance Abuse Care |
$15/visit (visits 1-20)
45% coinsurance/visit (visits 21+)
|
| Outpatient Surgery |
$50 |
$150/visit |
| Ambulance Services |
$100 for each one-way trip
|
| Emergency Care (waived if admitted to inpatient hospital care) |
$50
($5,000 combined maximum for emergency and urgent care services outside the U.S.)
|
| Urgently Needed Care (within U.S.) |
$25
|
| Urgently Needed Care (outside of U.S.) |
$50
($5,000 combined maximum for emergency and urgent care services outside the U.S.)
|
| Outpatient Rehabilitation Services (includes occupational, physical and speech therapy) |
$10 (Medicare limits apply)
|
| OUTPATIENT MEDICAL SERVICES AND SUPPLIES* |
| Durable Medical Equipment |
20% coinsurance
|
| Infusion Therapy |
0%
|
| Prosthetic Devices |
20% 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 ($5,000 annual maximum)
|
| PREVENTIVE SERVICES* |
| Bone Mass Measurement |
$0
|
| Colorectal Screening Exam |
$0 (1st exam), $5 for additional exams; unlimited
|
| HIV Screenings |
$0
|
Immunizations
(Flu, pneumonia and hepatitis B) |
$0
|
| Mammograms |
$0 (1st exam), $5 for additional exams; unlimited
|
| Pap Smears / Pelvic Exams |
$0 (1st exam), $5 for additional exams; unlimited
|
| Prostate Cancer Screening Exams |
$0 (1st exam), $5 for additional exams; unlimited
|
Routine Physical Exams
one exam/year) |
$5 |
Not covered |
| TRANSPORTATION* |
| Transportation |
$5/trip for 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
|
| Health Club Membership |
$0 for health club membership
(including fitness classes)
|
| Health/Wellness Education/Services |
Nutritional training, smoking cessation, newsletter, disease management, nurseline
|
Hearing Services
(diagnostic hearing exam) |
$15 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 (1 per year) and
$0 for one pair of glasses or contacts per year
|
| PRESCRIPTION DRUG COVERAGE (PART D) |
| Generic Drugs |
$5 for a 30-day supply
|
| Preferred Brand-Name Drugs |
$30 for a 30-day supply
|
| 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) |
Two copays for 90-day supply
|