CareOne Plus (HMO-POS)

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0
Prior Authorization Required for Doctor Specialty Visit
Referral Required for Doctor Specialty Visit

Out-of-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services $0

Urgent Care:
Copayment for Urgent Care $0

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0

Emergency Care:
Copayment for Emergency Care $100
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100
Copayment for Worldwide Emergency Transportation $200

Out-of-Network:

Ambulance Services:
Copayment for Ambulance Services - Ground $0 to $200
Coinsurance for Ambulance Services - Air $20%
$200 Ambulance Emergency - Ground Ambulance$0 Ambulance Non-Emergency - Ground Ambulance

In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Copayment for Routine Care $0

• Maximum 12 Routine Care every year

Prior Authorization Required for Chiropractic Services

Out-of-Network:

Medicare Covered Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $0

In-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0

Out-of-Network:

Medicare Covered Durable Medical Equipment Services:
Copayment for Medicare Covered Durable Medical Equipment $0
Coinsurance for Medicare Covered Durable Medical Equipment 20%
$0 DME-All Other - DME Prov$0 DME-All Other - Pharmacy20% DME-High Cost - DME Prov20% DME-High Cost - Pharmacy

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $25
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Referral Required for Outpatient Diag Procs/Tests/Lab Services
$25 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$0 OP Diag Proc & Tests - SPC$0 OP Diag Proc & Tests - UCC$25 Sleep Study (Fac Based) - OPH$0 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $60
Copayment for Medicare-covered Therapeutic Radiological Services $0
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $25

In-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Referral Required for Home Health Services

Out-of-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital $0

In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0

Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $60
Copayment for Medicare Covered Ambulatory Surgical Center Services $0 to $20
$0 Diag Colonoscopy - OPH$0 Mental Health - OPH$60 Surgery Svcs - OPH$0 Wound Care - OPH

Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual Sessions $0
Copayment for Medicare Covered Group Sessions $0
In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior Authorization Required for Outpatient Substance Abuse Services
Referral Required for Outpatient Substance Abuse Services

In-Network:
$35 monthly allowance on a prepaid spending card. All plan members receive this amount to buy approved over the counter (OTC) health and wellness products at participating retailers or through the plan’s approved OTC mail order vendor. Plus, members may also use this money for eligible groceries, utilities, rent, and more if they have certain qualifying chronic condition(s) and meet other program criteria. Any unused amount rolls over each month and expires at the end of the plan year or upon disenrollment, whichever occurs first.

In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Copayment for Routine Foot Care $0
Prior Authorization Required for Podiatry Services

Out-of-Network:

Medicare Covered Podiatry Services:
Copayment for Medicare Covered Podiatry Services $0

Out-of-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$160 per day for days 21 to 100

In-Network:
$0 copayment for comprehensive oral exam up to 1 every 3 years.
$0 copayment for bridge recementation, bridges-pontic, complete or partial dentures up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant per year.
$0 copayment for denture adjustments, rebase, reline, panoramic film, root canal, scaling for moderate inflammation up to 1 per year.
$0 copayment for bitewing x-rays, emergency diagnostic exam, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for amalgam and/or composite filling, periodontal maintenance up to 4 per year.
$0 copayment for simple or surgical extraction up to 5 per year.
$0 copayment for necessary anesthesia with covered service up to as needed with covered codes per year.
$0 copayment for extractions for dentures up to unlimited per year.
Unlimited extractions are covered only for the purpose of member receiving dentures, all other extractions are limited to 5 per year.

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Eye Exams $0

• Maximum 1 Routine Eye Exams every year

Prior Authorization Required for Eye Exams
Referral Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
Copayment for Eyeglasses (lenses and frames) $0
Maximum Plan Benefit of $100 every year
Plan covers up to $100 for supplemental eyeglasses (frames, lenses) or contact lenses per year or 1 pair of select eyeglasses at no cost.

Out-of-Network:

Medicare Covered Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $0

Out-of-Network:

Medicare Covered Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0