Saint Alphonsus Health Plan Glory No RX (HMO)

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

• • In-Network: No

Comprehensive Dental

• Adjunctive General Services
  • In-Network: No Coins – 0.00 Copay
• Endodontics
  • In-Network: 70 Coins – No Co pay
• Oral and Maxillofacial Surgery
  • In-Network: 50 Coins – No Co pay
• Periodontics
  • In-Network: 70 Coins – No Co pay
• Restorative Services
  • In-Network: 50 Coins – No Co pay

Diagnostic and Preventive Dental

• Dental X-Rays
  • In-Network: No Coins – – Copay
• Fluoride Treatment
  • In-Network: No Coins – – Copay
• Oral Exams
  • In-Network: No Coins – – Copay
• Other Diagnostic Dental Services
  • In-Network: No Coins – – Copay
• Other Preventive Dental Services
  • In-Network: No Coins – – Copay
• Prophylaxis (cleaning)
  • In-Network: No Coins – – Copay

Diagnostic procedures/lab services/imaging

• Diagnostic radiology services (e.g., MRI)
  • $150 copay
• Outpatient x-rays
  • $10 copay
• Diagnostic tests and procedures
  • $10 copay (Authorization Required)
• Lab services
  • $0 copay (Authorization Required)

Doctor visits

• Primary
  • $0 copay
• Specialist
  • $25 copay per visit

Emergency care/Urgent care

• Emergency
  • $110 copay per visit (always covered)
• Urgent care
  • $30 copay per visit (always covered)

Foot care (podiatry services)

• Foot exams and treatment
  • $25 copay
• Routine foot care
  • Not covered

Ground ambulance

• • $225 copay

Health plan deductible

• • $0

Hearing

• Hearing aids OTC
  • Not covered
• Fitting/evaluation
  • $0 copay
• Hearing aids
  • $399-699 copay (Limits Apply)
• Medicare-Covered Hearing Exam
  • $25 copay

Inpatient hospital coverage

• • $275 per day for days 1 through 5
    $0 per day for days 6 through 90 (Authorization Required)

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

• • $4,500 In-network

Medical equipment/supplies

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

Medicare Part B drugs

• Chemotherapy
  • 0-20% coinsurance (Authorization Required)
• Other Part B drugs
  • 0-20% coinsurance (Authorization Required)

Mental health services

• Outpatient group therapy visit
  • $20 copay
• Outpatient individual therapy visit with a psychiatrist
  • $20 copay
• Outpatient group therapy visit with a psychiatrist
  • $20 copay
• Inpatient hospital – psychiatric
  • $275 per day for days 1 through 5
    $0 per day for days 6 through 90 (Authorization Required)
• Outpatient individual therapy visit
  • $20 copay

Optional supplemental benefits

• • Yes

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • $0-275 copay per visit

Preventive care

• • $0 copay

Rehabilitation services

• Physical therapy and speech and language therapy visit
  • $20 copay
• Occupational therapy visit
  • $20 copay

Skilled Nursing Facility

• • $0 per day for days 1 through 20
    $214 per day for days 21 through 55
    $0 per day for days 56 through 100

Transportation

• • Not covered

Vision

• Contact lenses
  • $0 copay (Limits Apply)
• Eyeglass frames
  • $0 copay (Limits Apply)
• Other
  • Not covered
• Routine eye exam
  • $0 copay (Limits Apply)
• Eyeglass lenses
  • $0 copay (Limits Apply)
• Eyeglasses (frames and lenses)
  • $0 copay (Limits Apply)
• Upgrades
  • Not covered

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

• • Covered

Dental Silver

Comprehensive Dental

• Restorative Services, Endodontics, Periodontics, Oral and Maxillofacial Surgery, Adjunctive General Services
  • Monthly Premium: $18.00
  • Max Coverage: $500.00
  • Coverage Periodicity: Every year

Diagnostic and Preventive Dental

• Other Diagnostic Dental Services, Other Preventive Dental Services
  • Monthly Premium: $18.00
  • Max Coverage: $500.00
  • Coverage Periodicity: Every year