Central Health Classic Care Plan I (HMO) - H5649-027-000

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

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0
Prior Authorization Required for Doctor Specialty Visit
Referral Required for Doctor Specialty Visit

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services

Urgent Care:
Copayment for Urgent Care $0

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $140
Maximum Plan Benefit of $50,000

Emergency Care:
Copayment for Emergency Care $100
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 3 days.

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $140
Copayment for Worldwide Emergency Transportation $140
Maximum Plan Benefit of $50,000

Ground Ambulance:
Copayment for Ground Ambulance Services $0 to $150
Minimum copayment for transfer from OON hospital to an INN hospital. Maximum copayment for all other ambulance services.

Prior authorization required for non-emergent ambulance only.

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

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Copayment for Routine Care $0

• Maximum 30 Routine Care every year combined with Routine Acupuncture services.

Prior Authorization Required for Chiropractic Services
Referral Required for Chiropractic Services

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0
Prior authorization may be required. Prior authorization is not required for preferred manufacturer.

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
Minimum coinsurance for items $100 or less, maximum coinsurance for items greater than $100.

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0
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

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

Referral Required for Outpatient Diag/Therapeutic Rad Services

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Referral Required for Home Health Services

Psychiatric Hospital Services:
$150 per day for days 1 to 6
$0 per day for days 7 to 90

$658 copay per day for each lifetime reserve day
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior authorization required for outpatient mental health care.

Referral required for outpatient mental health care.

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $65
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services
Minimum amount for diagnostic colonoscopies in an outpatient setting. Maximum amount for all other services.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $65
Prior Authorization Required for Outpatient Observation Services
Referral Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services

Outpatient Substance Abuse Services:
Coinsurance for Medicare-covered Individual Sessions 20%
Coinsurance for Medicare-covered Group Sessions 20%
Prior Authorization Required for Outpatient Substance Abuse Services
Referral Required for Outpatient Substance Abuse Services

$150 combined allowance every 3 months for OTC items.

OTC benefit includes access to OTC hearing aids and herbal products through catalog purchase only.

Unused allowance does not carry over to the next month.

Please see the Flexible Extras section for a complete list of benefits and services that are included in the combined allowance.

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Prior Authorization Required for Podiatry Services
Referral Required for Podiatry Services

Skilled Nursing Facility Services:
Copayment for Skilled Nursing Facility Services per Stay $0
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services

Medicare Covered Preventive Dental:
Copayment for Office Visit $0
Prior Authorization Required for Medicare Covered Preventive Dental

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0

• Maximum 2 visits every year

Copayment for Dental x-rays $0

• Maximum 2 visits every year

Copayment for Other diagnostic services $0 to $6
Copayment for Prophylaxis $0

• Maximum 2 visits every year

Copayment for Fluoride treatment $0

• Maximum 2 visits every year

Copayment for Other preventive services $0 to $20

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Copayment for Restorative services $25 to $400
Copayment for Endodontics $25 to $720
Copayment for Periodontics $0 to $780
Copayment for Prothodontics, removable $0 to $600
Copayment for Implant services $45 to $2160
Copayment for Prothodontics, fixed $0 to $840
Copayment for Maxillofacial surgery $0 to $380
Copayment for Adjunctive general services $0 to $300

Eye Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Eye Exams $0

• Maximum 1 Routine Eye Exams every year

Prior Authorization Required for Eye Exams
Referral Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
Copayment for Eyeglasses (lenses and frames) $0

• Maximum 1 Pair every year

Copayment for Eyeglass Lenses $0

• Maximum 1 Pair every year

Copayment for Eyeglass Frames $0

• Maximum 1 Pair every year

Copayment for Upgrades $0
Maximum Plan Benefit of $300 every year
Referral Required for Eyewear
Prior authorization may be required.

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

• Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0

• Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $575 to $2099

• Maximum 2 Hearing Aids every year

$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

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Summary of benefits
• Evidence of coverage
• Star ratings