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Providence Health Plan is a health plan with a Medicare contract. - page 24 / 32

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SUMMARY OF BENEFITS

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

Benefit Category 34 - Health/Wellness

Education

Original Medicare

Smoking Cessation: Covered if ordered by your doctor.

Includes two counseling

attempts within a 12-month period if you are diagnosed with a smoking-related

illness or are taking medicin that may be affected by tobacco. Each counseling attempt includes up to four face-to-face visits. You pay coinsurance, and Part B deductible applies.

e

Providence Medicare Extra + RX In-Network

The plan covers the following

health/wellness education benefits:

Written health education

materials, including newsletters. Nutritional Training. Additional Smoking Cessation Nursing Hotline. Other Wellness Benefits.

$0 copay for the HIV screening, but you generally pay 20% of the Medicare- approved amount for the doctor's visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.

$0 copay for each Medicare- covered smoking cessation counseling session.

$0 copay for each Medicare- covered HIV screening.

HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.

Transportation (routine)

Not covered.

In-Network

This plan does not cover routine transportation.

Acupuncture

Not covered.

In-Network

This plan does not cover acupuncture.

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