Molina Complete Care for MyCare Ohio (HMO D-SNP) - H9955-008-000

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

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0

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

Ground Ambulance:
Copayment for Ground Ambulance Services $0

Prior authorization required for non-emergent ambulance only.

Air Ambulance:
Copayment for Air Ambulance Services $0
Prior Authorization Required for Air Ambulance

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

• Maximum 12 Routine Care every year

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 required for diabetic shoes and inserts. Prior authorization is not required for preferred manufacturer.

Durable Medical Equipment:
Copayment for Medicare-covered Durable Medical Equipment $0
Prior authorization may be required. Prior authorization is not required for preferred manufacturers.

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

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0
Copayment for Medicare-covered Therapeutic Radiological Services $0
Copayment for Medicare-covered X-Ray Services $0

Prior authorization may be required for some services. No authorization is required for outpatient lab services and outpatient x-ray services. Genetic lab testing requires prior authorization.

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

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0
Prior Authorization 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 may be required.

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0
Prior Authorization Required for Outpatient Observation Services

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

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior Authorization Required for Outpatient Substance Abuse Services

$230 combined allowance every month for OTC items.

OTC hearing aids are covered and included in the combined OTC allowance.

Unused allowance does not carry over to the next month. Please see the Flexible Extras section for a complete list of benefit and services that are included in the combined allowance.

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

Medicare Covered Preventive Dental:
Copayment for Office Visit $0

$6,000 maximum plan benefit coverage amount each year for select comprehensive dental services such as Restorative, Endodontics, Prosthodontics (removable), Oral and Maxillofacial Surgery and Adjunctive General Services through a Molina Value Added Service Benefit.

Eye Exams:
Copayment for Medicare Covered Benefits $0

$300 maximum eyewear allowance every year for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, upgrades through a Molina Value Added Service Benefit.

Hearing Exams:
Copayment for Medicare Covered Benefits $0

1 hearing aid for each ear (2 combined) Every 2 Years and hearing aid fitting each year when necessary, through a Molina Value Added Service Benefit.

$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

• Summary of benefits
• Evidence of coverage
• Star ratings