X hits on this document

PDF document

Providence Health Plan is a health plan with a Medicare contract. - page 22 / 32

68 views

0 shares

0 downloads

0 comments

22 / 32

SUMMARY OF BENEFITS

If you have any questions about this plan’s benefits or costs, please contact Providence Health Plan.

Benefit Category

Original Medicare

Providence Medicare Extra + RX

29 - Prescription Drugs (continued)

You will not be reimbursed for the difference between the Out-of- Network Pharmacy charge and the plan's In-Network allowable amount.

Out-of-Network Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $ 4,550, you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share, which is the greater of:

A $2.50 copay for generic (including brand drugs treated as generic) and a $6.30 copay for all other drugs, or 5% coinsurance.

You will not be reimbursed for the difference between the Out-of- Network Pharmacy charge and the plan's In-Network allowable amount

30 - Dental Services

Preventive dental services (such as cleaning) not covered.

General Authorization rules may apply.

In-Network

In general, preventive dental benefits (such as cleaning) not covered.

$15 copay for Medicare-covered dental benefits.

Separate Office Visit cost sharing of $15 may apply.

22

Document info
Document views68
Page views68
Page last viewedSun Dec 04 21:58:45 UTC 2016
Pages32
Paragraphs574
Words8210

Comments