Personal Choice 65 Medical Only (PPO)

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

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

Comprehensive Dental

• Adjunctive General Services
  • In-Network: No Coins – 0.00 Copay (Limits Apply)
  • Out-of-Network: 80% Coins – No Copay (Limits Apply)
• Endodontics
  • In-Network: 20 Coins – No Co pay
  • Out-of-Network: 80% Coins – No Copay
• Implant Services
  • In-Network: 40 Coins – No Co pay
  • Out-of-Network: 80% Coins – No Copay
• Oral and Maxillofacial Surgery
  • In-Network: 20-40 Coins – No Co pay (Limits Apply)
  • Out-of-Network: 80% Coins – No Copay (Limits Apply)
• Periodontics
  • In-Network: 20 Coins – No Co pay
  • Out-of-Network: 80% Coins – No Copay
• Prosthodontics, fixed
  • In-Network: 40 Coins – No Co pay
  • Out-of-Network: 80% Coins – No Copay
• Prosthodontics, removable
  • In-Network: 40 Coins – No Co pay
  • Out-of-Network: 80% Coins – No Copay
• Restorative Services
  • In-Network: 20 Coins – No Co pay
  • Out-of-Network: 80% Coins – No Copay

Diagnostic and Preventive Dental

• Dental X-Rays
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: 80% Coins – No Copay
• Fluoride Treatment
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: 80% Coins – No Copay
• Oral Exams
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: 80% Coins – No Copay
• Prophylaxis (cleaning)
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: 80% Coins – No Copay

Diagnostic procedures/lab services/imaging

• Diagnostic tests and procedures
  • Out-of-Network: 30% coinsurance (Authorization Required)
• Diagnostic radiology services (e.g., MRI)
  • In-Network: $0-175 copay (Authorization Required)
• Lab services
  • In-Network: $0 copay (Authorization Required)
  • Out-of-Network: 30% coinsurance (Authorization Required)
• Diagnostic radiology services (e.g., MRI)
  • Out-of-Network: 30% coinsurance (Authorization Required)
• Diagnostic tests and procedures
  • In-Network: $0 copay (Authorization Required)
• Outpatient x-rays
  • In-Network: $40 copay (Authorization Required)
  • Out-of-Network: 30% coinsurance (Authorization Required)

Doctor visits

• Primary
  • In-Network: $0 copay
• Specialist
  • In-Network: $35 copay per visit
• Primary
  • Out-of-Network: 30% coinsurance per visit
• Specialist
  • Out-of-Network: 30% coinsurance per visit

Emergency care/Urgent care

• Emergency
  • $125 copay per visit (always covered)
• Urgent care
  • $5-55 copay per visit (always covered)

Foot care (podiatry services)

• Foot exams and treatment
  • Out-of-Network: 30% coinsurance
• Routine foot care
  • In-Network: $20 copay (Limits Apply)
• Foot exams and treatment
  • In-Network: $20 copay

Ground ambulance

• • Out-of-Network: $175 copay
  • In-Network: $175 copay

Health plan deductible

• • $0

Hearing

• Fitting/evaluation
  • Out-of-Network: $0 copay
• Hearing aids
  • Out-of-Network: $499-799 copay (Limits Apply)
  • In-Network: $499-799 copay (Limits Apply)
• Hearing aids OTC
  • Not covered
• Medicare-Covered Hearing Exam
  • Out-of-Network: 30% coinsurance
• Fitting/evaluation
  • In-Network: $0 copay
• Medicare-Covered Hearing Exam
  • In-Network: $35 copay

Inpatient hospital coverage

• • In-Network: $240 per day for days 1 through 6
    $0 per day for days 7 through 90
    $0 per day for days 91 and beyond (Authorization Required)
  • Out-of-Network: 30% per stay (Authorization Required)

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

• • $8,950 In and Out-of-network
    $5,500 In-network

Medical equipment/supplies

• Durable medical equipment (e.g., wheelchairs, oxygen)
  • In-Network: 20% coinsurance per item (Authorization Required)
• Prosthetics (e.g., braces, artificial limbs)
  • In-Network: 20% coinsurance per item (Authorization Required)
  • Out-of-Network: 30% coinsurance per item (Authorization Required)
• Diabetes supplies
  • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Out-of-Network: 30% coinsurance per item (Authorization Required)
• Durable medical equipment (e.g., wheelchairs, oxygen)
  • Out-of-Network: 30% coinsurance per item (Authorization Required)

Medicare Part B drugs

• Chemotherapy
  • In-Network: 0-20% coinsurance (Authorization Required)
• Other Part B drugs
  • In-Network: 0-20% coinsurance (Authorization Required)
• Chemotherapy
  • Out-of-Network: 30% coinsurance (Authorization Required)
• Other Part B drugs
  • Out-of-Network: 30% coinsurance (Authorization Required)

Mental health services

• Outpatient group therapy visit
  • In-Network: $20 copay (Authorization Required)
• Outpatient group therapy visit with a psychiatrist
  • In-Network: $20 copay
• Outpatient individual therapy visit
  • In-Network: $30 copay (Authorization Required)
• Inpatient hospital – psychiatric
  • Out-of-Network: 30% per stay (Authorization Required)
• Outpatient group therapy visit with a psychiatrist
  • Out-of-Network: 30% coinsurance
• Inpatient hospital – psychiatric
  • In-Network: $240 per day for days 1 through 6
    $0 per day for days 7 through 90 (Authorization Required)
• Outpatient group therapy visit
  • Out-of-Network: 30% coinsurance (Authorization Required)
• Outpatient individual therapy visit
  • Out-of-Network: 30% coinsurance (Authorization Required)
• Outpatient individual therapy visit with a psychiatrist
  • In-Network: $30 copay
  • Out-of-Network: 30% coinsurance

Optional supplemental benefits

• • No

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • In-Network: $300 copay per visit (Authorization Required)
  • Out-of-Network: 30% coinsurance per visit (Authorization Required)

Preventive care

• • In-Network: $0 copay (Authorization Required)
  • Out-of-Network: 30% coinsurance (Authorization Required)

Rehabilitation services

• Physical therapy and speech and language therapy visit
  • Out-of-Network: 30% coinsurance
• Occupational therapy visit
  • In-Network: $20 copay
• Physical therapy and speech and language therapy visit
  • In-Network: $20 copay
• Occupational therapy visit
  • Out-of-Network: 30% coinsurance

Skilled Nursing Facility

• • Out-of-Network: 30% per stay (Authorization Required)
  • In-Network: $0 per day for days 1 through 20
    $214 per day for days 21 through 100 (Authorization Required)

Transportation

• • Not covered

Vision

• Routine eye exam
  • In-Network: $0 copay (Limits Apply)
• Contact lenses
  • In-Network: $0 copay (Limits Apply)
  • Out-of-Network: 80% coinsurance (Limits Apply)
• Eyeglass lenses
  • Not covered
• Eyeglasses (frames and lenses)
  • In-Network: $0 copay (Limits Apply)
• Other
  • Not covered
• Routine eye exam
  • Out-of-Network: 80% coinsurance (Limits Apply)
• Upgrades
  • Not covered
• Eyeglass frames
  • Not covered
• Eyeglasses (frames and lenses)
  • Out-of-Network: 80% coinsurance (Limits Apply)

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

• • Covered