Retiree - Medicare Eligible Health Plan
Medicare Advantage Option Summary of Health Plan Benefits
2009 January-December |
Major Plan Benefits |
Plan Benefits for Covered Services |
Out-of-Pocket Maximum
|
If you reach this maximum, no further out-of-pocket will be required of you for covered expenses during the year. Expenses for outpatient prescription drugs, Medicare-covered diabetic supplies, care during foreign travel, and plan premiums do not apply toward this maximum. |
$2,500 per calendar year |
| Lifetime Maximum Benefit | Unlimited | |
Preventive Care |
• Office visits in conjunction with an illness or injury • Allergy injections and serum • Diagnostic tests and X-rays |
100% after $5 copayment
per visit to primary care doctor |
• Preventive care
|
100% when no other services are provided during the visit. If other services are provided during the visit, you pay $5 to $50 per visit, based on where the services are received. | |
Hospital Services
|
• Inpatient hospital care |
100% after $175 copayment per admission |
• Preadmission testing |
100% |
|
| • Outpatient hospital care | 100% after $50 copayment per visit | |
| • Emergency Care (emergency room, emergency services) | 100% after $50 copayment per visit | |
• Ambulatory surgical center care |
100% after $15 copayment per visit |
|
Other Medical Services
|
• Physical therapy, respiratory, occupational, or speech therapy | 100% after $15 copayment per visit |
| • Home health services | 100% | |
| • Durable medical equipment | 100% after 20% coinsurance | |
| • Oxygen | 100% after 20% coinsurance | |
• Skilled nursing facility |
100% for days 1-20, |
|
| • Ambulance | 100% after $50 copayment per date of service | |
| • Immediate care facility | 100% after $15 copayment per visit | |
Mental and |
• Inpatient hospital care |
100% after $175 copayment per admission |
| • Outpatient care | 100% after $15 to $50 copayment per visit, based on where services are received |
|
| • Partial hospitalization | 100% after $15 copayment per date of service | |
| *Inpatient hospital admissions do not require prior authorization. However, notification of hospital admissions is requested. | ||
