CareOne Plus Local (HMO-POS)

In-Network:

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

Out-of-Network:

Doctor Specialty Visit Services:
Coinsurance for Physician Specialist Office Visit $25%

In-Network:

Acute Hospital Services:
$175 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services

Urgent Care:
Copayment for Urgent Care $50

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $50

Emergency Care:
Copayment for Emergency Care $150
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 $150
Copayment for Worldwide Emergency Transportation $240

In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $120 to $240
$240 Ambulance Emergency - Ground Ambulance$120 Ambulance Non-Emergency - Ground Ambulance

Air Ambulance:
Coinsurance for Air Ambulance Services $20%
Prior Authorization Required for Air Ambulance

Out-of-Network:

Medicare Covered Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 25%
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20
Copayment for Routine Care $20

• Maximum 12 Routine Care every year

Prior Authorization Required for Chiropractic Services

In-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $5 to $10

In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $185
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
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
20% OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$30 OP Diag Proc & Tests - SPC$25 OP Diag Proc & Tests - UCC20% Sleep Study (Fac Based) - OPH$185 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 $335
Copayment for Medicare-covered Therapeutic Radiological Services $30
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $40
Coinsurance for Medicare-covered X-Ray Services 20%

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

In-Network:

Psychiatric Hospital Services:
$175 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services

In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $30
Copayment for Medicare-covered Group Sessions $30

Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0
Coinsurance for Medicare Covered Outpatient Hospital Services 25%
Copayment for Medicare Covered Ambulatory Surgical Center Services $0
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 25%
$0 Diag Colonoscopy - OPH$30 Mental Health - OPH$165 Surgery Svcs - OPH$30 Wound Care - OPH

In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $30
Copayment for Medicare-covered Group Sessions $30
Prior Authorization Required for Outpatient Substance Abuse Services
Referral Required for Outpatient Substance Abuse Services

Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 25%
Coinsurance for Medicare Covered Group Sessions 25%

In-Network:
$10 monthly allowance to buy approved over-the-counter health and wellness products available through our OTC Mail Order provider.
Unused amount expires at the end of the month.

Out-of-Network:

Medicare Covered Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 25%
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $30
Copayment for Routine Foot Care $30
Prior Authorization Required for Podiatry Services

Out-of-Network:

Skilled Nursing Facility Services:
Coinsurance for Skilled Nursing Facility per Stay 25%

In-Network:
$0 copayment for comprehensive oral exam up to 1 every 3 years.
$0 copayment for complete or partial dentures up to 1 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 to $30
Copayment for Routine Eye Exams $0

• Maximum 1 Routine Eye Exams every year

Prior Authorization Required for Eye Exams
Referral Required for Eye Exams
$0 Diab Eye Exam - All POTs$30 Vision Svcs (MC) - SPC

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
Copayment for Eyeglasses (lenses and frames) $0
Maximum Plan Benefit of $150 every year
Plan covers up to $150 for supplemental eyeglasses (frames, lenses) or contact lenses per year or 1 pair of select eyeglasses at no cost.

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $30
Copayment for Routine Hearing Exams $0

• Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0

• Maximum 4 visits every year

Prior Authorization Required for Hearing Exams
Referral Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $575 to $750

• Maximum 2 Hearing Aids every year

In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

• COVID-19 shots
• Flu shots
• Hepatitis B shots
• Pneumococcal shots

Tobacco use cessation
Yearly "Wellness" visit