Medica Prime Solution Thrift (Cost)

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

• • In-Network: No

Diagnostic procedures/lab services/imaging

• Lab services
  • $0 copay
• Outpatient x-rays
  • 20% coinsurance
• Diagnostic radiology services (e.g., MRI)
  • 20% coinsurance
• Diagnostic tests and procedures
  • 20% coinsurance

Doctor visits

• Primary
  • 20% coinsurance per visit
• Specialist
  • 20% coinsurance per visit

Emergency care/Urgent care

• Emergency
  • $50 copay per visit (always covered)
• Urgent care
  • $25 copay per visit (always covered)

Foot care (podiatry services)

• Foot exams and treatment
  • 20% coinsurance
• Routine foot care
  • Not covered

Ground ambulance

• • 20% coinsurance

Health plan deductible

• • $50 In-network

Hearing

• Hearing aids – inner ear
  • Not covered
• Hearing aids OTC
  • Not covered
• Fitting/evaluation
  • Not covered
• Hearing aids – over the ear
  • Not covered
• Hearing aids – outer ear
  • Not covered
• Medicare-Covered Hearing Exam
  • 20% coinsurance

Inpatient hospital coverage

• • $300 per day for days 1 through 4
    $0 per day for days 5 through 90

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

• • $6,700 In-network

Medical equipment/supplies

• Durable medical equipment (e.g., wheelchairs, oxygen)
  • 20% coinsurance per item
• Prosthetics (e.g., braces, artificial limbs)
  • 20% coinsurance per item
• Diabetes supplies
  • 0-20% coinsurance per item

Medicare Part B drugs

• Chemotherapy
  • 0-20% coinsurance
• Other Part B drugs
  • 0-20% coinsurance

Mental health services

• Inpatient hospital – psychiatric
  • $300 per day for days 1 through 4
    $0 per day for days 5 through 90
• Outpatient group therapy visit
  • 20% coinsurance
• Outpatient group therapy visit with a psychiatrist
  • 20% coinsurance
• Outpatient individual therapy visit
  • 20% coinsurance
• Outpatient individual therapy visit with a psychiatrist
  • 20% coinsurance

Optional supplemental benefits

• • No

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • 20% coinsurance per visit

Preventive care

• • $0 copay

Rehabilitation services

• Physical therapy and speech and language therapy visit
  • 20% coinsurance
• Occupational therapy visit
  • 20% coinsurance

Skilled Nursing Facility

• • $0 per day for days 1 through 20
    $214 per day for days 21 through 100

Transportation

• • Not covered

Vision

• Eyeglasses (frames and lenses)
  • Not covered
• Other
  • Not covered
• Contact lenses
  • Not covered
• Eyeglass lenses
  • Not covered
• Upgrades
  • Not covered
• Eyeglass frames
  • Not covered
• Routine eye exam
  • Not covered

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

• • Covered