Legacy Rx (HMO-POS)

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

• • In-Network: Yes, contact plan for further details

Diagnostic and Preventive Dental

• Dental X-Rays
  • In-Network: No Coins – No Copay
• Oral Exams
  • In-Network: No Coins – No Copay
• Prophylaxis (cleaning)
  • In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

• Diagnostic radiology services (e.g., MRI)
  • In-Network: $150 copay (Authorization Required)
  • Out-of-Network: $150 copay (Authorization Required)
• Outpatient x-rays
  • Out-of-Network: $0 copay (Authorization Required)
• Diagnostic tests and procedures
  • In-Network: $0 copay (Authorization Required)
  • Out-of-Network: $0 copay (Authorization Required)
• Lab services
  • Out-of-Network: $0 copay (Authorization Required)
  • In-Network: $0 copay (Authorization Required)
• Outpatient x-rays
  • In-Network: $0 copay (Authorization Required)

Doctor visits

• Specialist
  • In-Network: $25 copay per visit
• Primary
  • In-Network: $0 copay
  • Out-of-Network: $0 copay
• Specialist
  • Out-of-Network: $25 copay per visit

Emergency care/Urgent care

• Emergency
  • $125 copay per visit (always covered)
• Urgent care
  • $0-25 copay per visit (always covered)

Foot care (podiatry services)

• Foot exams and treatment
  • In-Network: $25 copay
  • Out-of-Network: $25 copay
• Routine foot care
  • Not covered

Ground ambulance

• • In-Network: $175 copay

Health plan deductible

• • $0

Hearing

• Fitting/evaluation
  • Out-of-Network: $25 copay
• Hearing aids OTC
  • Not covered
• Medicare-Covered Hearing Exam
  • In-Network: $25 copay
• Fitting/evaluation
  • In-Network: $25 copay
• Hearing aids
  • In-Network: $500 copay (Limits Apply)
• Medicare-Covered Hearing Exam
  • Out-of-Network: $25 copay

Inpatient hospital coverage

• • In-Network: $250 per stay (Authorization Required)
  • Out-of-Network: $250 per stay (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

• • $2,000 In and Out-of-network
    $2,000 In-network
    $2,000 Out-of-network

Medical equipment/supplies

• Diabetes supplies
  • In-Network: $0 copay (Authorization Required)
• Prosthetics (e.g., braces, artificial limbs)
  • In-Network: 20% coinsurance per item (Authorization Required)
• Durable medical equipment (e.g., wheelchairs, oxygen)
  • In-Network: 0-20% coinsurance per item (Authorization Required)

Medicare Part B drugs

• Other Part B drugs
  • In-Network: 0-20% coinsurance (Authorization Required)
  • Out-of-Network: 0-20% coinsurance (Authorization Required)
• Chemotherapy
  • In-Network: 0-20% coinsurance (Authorization Required)
  • Out-of-Network: 0-20% coinsurance (Authorization Required)

Mental health services

• Outpatient group therapy visit
  • In-Network: $25 copay
• Outpatient group therapy visit with a psychiatrist
  • In-Network: $25 copay
• Outpatient group therapy visit
  • Out-of-Network: $25 copay
• Outpatient individual therapy visit
  • Out-of-Network: $25 copay
• Outpatient individual therapy visit with a psychiatrist
  • In-Network: $25 copay
  • Out-of-Network: $25 copay
• Inpatient hospital – psychiatric
  • In-Network: $250 per stay (Authorization Required)
  • Out-of-Network: $250 per stay (Authorization Required)
• Outpatient group therapy visit with a psychiatrist
  • Out-of-Network: $25 copay
• Outpatient individual therapy visit
  • In-Network: $25 copay

Optional supplemental benefits

• • Yes

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • In-Network: $0-100 copay per visit (Authorization Required)
  • Out-of-Network: $0-100 copay per visit (Authorization Required)

Preventive care

• • Out-of-Network: $0 copay
  • In-Network: $0 copay

Rehabilitation services

• Physical therapy and speech and language therapy visit
  • In-Network: $20 copay (Authorization Required)
• Occupational therapy visit
  • In-Network: $20 copay (Authorization Required)
  • Out-of-Network: $20 copay (Authorization Required)
• Physical therapy and speech and language therapy visit
  • Out-of-Network: $20 copay (Authorization Required)

Skilled Nursing Facility

• • Out-of-Network: $0 per day for days 1 through 6
    $20 per day for days 7 through 20
    $0 per day for days 21 through 100 (Authorization Required)
  • In-Network: $0 per day for days 1 through 6
    $20 per day for days 7 through 20
    $0 per day for days 21 through 100 (Authorization Required)

Transportation

• • Not covered

Vision

• Eyeglass lenses
  • Not covered
• Other
  • In-Network: $0-25 copay
• Routine eye exam
  • Out-of-Network: $0-25 copay
• Eyeglasses (frames and lenses)
  • In-Network: $0 copay (Limits Apply)
• Other
  • Out-of-Network: $0-25 copay
• Upgrades
  • Not covered
• Eyeglass frames
  • Not covered
• Contact lenses
  • Not covered
• Routine eye exam
  • In-Network: $0-25 copay

Wellness programs (e.g., fitness, nursing hotline)

• • Covered (Authorization Required)

Optional Dental

Comprehensive Dental

• Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Implant Services, Prosthodontics, fixed, Oral and Maxillofacial Surgery, Adjunctive General Services
  • Monthly Premium: $43.00
  • Max Coverage: $1500.00
  • Coverage Periodicity: Every year
  • Deductible Services: 16c1: Restorative Services, 16c2: Endodontics, 16c3: Periodontics, 16c4: Prosthodontics, removable, 16c6: Implant Services, 16c7: Prosthodontics, fixed, 16c8: Oral and Maxillofacial Surgery, 16c10: Adjunctive General Services
  • Deductible: $100.00

Diagnostic and Preventive Dental

• Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment
  • Monthly Premium: $43.00
  • Max Coverage: $1500.00
  • Coverage Periodicity: Every year
  • Deductible Services: 16b3: Other Diagnostic Dental Services
  • Deductible: $100.00