X hits on this document

PDF document

Providence Health Plan is a health plan with a Medicare contract. - page 23 / 32

60 views

0 shares

0 downloads

0 comments

23 / 32

SUMMARY OF BENEFITS

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

Benefit Category

31 - Hearing Services

Original Medicare Routine hearing exams and

hearing aids not covered.

Providence Medicare Extra + RX General

Authorization rules may apply.

20% coinsurance for diagnostic hearing exams.

In-Network

In general, routine hearing exams and hearing aids not covered.

$15 copay for Medicare-covered diagnostic hearing exams.

32 - Vision Services

20% coinsurance for diagnosis and treatment of diseases and conditions of the eye.

General Authorization rules may apply.

Routine eye exams and glasses not covered.

Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery.

Annual glaucoma screenings covered for people at risk.

In-Network

$0 copay for: one pair of eyeglasses or contact lenses after cataract surgery $0 copay for exams to diagnose and treat diseases and conditions of the eye.

$15 copay for up to 1 routine eye exam(s) every two years.

33 - Welcome to Medicare; and Annual Wellness Visit

When you join Medicare Part B, then you are eligible as follows.

In-Network $0 copay for routine exams.

During the first 12 months of your new Part B coverage, you can get either a Welcome to Medicare exam or an Annual Wellness visit.

Limited to 1 exam(s) every year.

Separate Office Visit cost sharing of $15 may apply.

After your first 12 months, you can get one Annual Wellness visit every 12 months.

There is no coinsurance, copayment or deductible for either the Welcome to Medicare exam or the Annual Wellness visit.

The Welcome to Medicare exam does not include lab tests.

23

Document info
Document views60
Page views60
Page last viewedFri Dec 02 18:49:27 UTC 2016
Pages32
Paragraphs574
Words8210

Comments