Medical Benefits Comparison Book 2017 Medicare Retirees in the Rochester Area

Transcription

1 Medical Benefits Comparison Book 2017 Medicare Retirees in the Rochester Area Human Resources Finance & Administration Rochester Institute of Technology

2 Medical Benefit Comparison This information provides a comparison of the major provisions of each medical plan -- it is not a contract. It is intended to highlight the coverage of the various plans; benefits are determined by the terms of the contract. If there is any confusion or conflict regarding plan features, the governing plan document/contract will be the final authority. The University intends to continue these benefit plans indefinitely, but reserves the right to modify or terminate such plans at any time with or without notice. Participation in these plans is provided to eligible retirees, surviving spouses and those on LTD and requires continued eligibility and is subject to the terms and conditions of the Plan Documents. GENERAL INFMATION... 4 Plan Availability... 4 Contacting the Carrier... 4 Deductible Carry Over... 4 Deductible and Annual Out of Pocket Maximum... 4 Referrals... 4 SERVICES (STED ALPHABETICALLY)... 5 Acupuncture... 5 Allergy Tests & Injections... 5 Ambulance... 5 Chemical Dependence-Inpatient... 5 Chemical Dependence-Outpatient... 6 Chemotherapy... 6 Chiropractic Services... 6 Dental... 6 Diabetic Supplies... 7 Durable Medical Equipment (DME)... 7 Emergency Care... 7 Eye Exams and Eyewear... 8 Health and Wellness... 9 Hearing Evaluations & Hearing Aids... 9 Home Health Care Hospice Hospital Pre-admission Testing Hospital Services-Inpatient Hospital Outpatient or Ambulatory Surgical Center Kidney Dialysis Laboratory & Pathology Mental Health-Inpatient Mental Health-Outpatient MRI, PET, CAT Scans Occupational Therapy Out of Area Coverage Physical Therapy Physician Visit In Office, Diagnostic (ill or injured) Physician Visits In Office, Routine Preventive Services Podiatry Prescription Drugs Covered Under Medical Plan LOCAL RETAIL PHARMACY-Coverage for 30-Day Supply LOCAL RETAIL PHARMACY-Coverage for 90-Day Supply MAIL DER-Coverage for 90-Day Supply Prosthetics (External) and Orthopedic Braces and Supports Prosthetics (Internal) Rochester Institute of Technology 2 Medicare-Eligible Plans Rochester Area

3 Radiation Therapy Respiratory Therapy Skilled Nursing Facility Speech Therapy Telemedicine Travel Benefit Urgent Care X-Ray-Diagnostic Rochester Institute of Technology 3 Medicare-Eligible Plans Rochester Area

4 General Information Plan Availability Medicare Blue Choice Plan 4 and 5 and 2 Available to retirees who live in the Rochester area at least six months of the year. Available to retirees who live in the Rochester area at least six months of the year. Contacting the Carrier Medicare Blue Choice Plan 4 and 5 Voice: (877) TTY: (585) Website: and 2 Voice: (800) TTY: (800) Website: Deductible Carry Over Medicare Blue Choice Plan 4 and 5 and 2 None. None. Deductible and Annual Out of Pocket Maximum Medicare Blue Choice Plan 4 Medicare Blue Choice Plan 5 and 2 No deductible $3,400 annual out-of-pocket maximum No deductible $5,500 annual out-of-pocket maximum No deductible $4,000 annual out-of-pocket maximum In Network (excludes: Part D costs, acupuncture, eyewear, hearing aids, and dental, if applicable) Referrals Medicare Blue Choice Plan 4 and 5 and 2 Required (open ended referrals are honored). Not required. Rochester Institute of Technology 4 Medicare-Eligible Plans Rochester Area

5 Services (sorted alphabetically) Acupuncture Medicare Blue Choice Plan 4 Covered at 50% for up to 10 visits per member per calendar year. Medicare Blue Choice Plan 5 Covered at 50% for up to 10 visits per member per calendar year. Covered at 50% for up to 10 visits per member per calendar year. Covered at 50% for up to 10 visits per member per calendar year. Allergy Tests & Injections Medicare Blue Choice Plan 4 $20 copay per visit. Serum covered in full. Medicare Blue Choice Plan 5 $50 copay per visit. Serum covered in full. Ambulance Medicare Blue Choice Plan 4 $65 copay Medicare Blue Choice Plan 5 $75 copay $15 copay per Primary Care Physician visit. $30 copay per Specialist visit. Serum covered in full. $15 copay per Primary Care Physician visit. $30 copay per Specialist visit. Serum covered in full. $100 copay $100 copay Chemical Dependence-Inpatient Medicare Blue Choice Plan 4 Unlimited days of hospital and physician care subject to the inpatient copay of $250; (Limit of 3 copays per calendar year, or $750). Medicare Blue Choice Plan 5 Unlimited days of hospital and physician care subject to the inpatient copay of $600; (Limit of 3 copays per calendar year, or $1,800). Unlimited days of hospital and physician care subject to the inpatient copay of $250; (Limit of 3 copays per calendar year, or $750). Unlimited days of hospital and physician care subject to the inpatient copay of $250; (Limit of 3 copays per calendar year, or $750). Rochester Institute of Technology 5 Medicare-Eligible Plans Rochester Area

6 Chemical Dependence-Outpatient Medicare Blue Choice Plan 4 20% coinsurance per visit Medicare Blue Choice Plan 5 20% coinsurance per visit $30 copay per visit. $30 copay per visit. Chemotherapy Medicare Blue Choice Plan 4 $20 copay, 20% coinsurance of the total cost for professionally administered Part B Drugs. Medicare Blue Choice Plan 5 $40 copay, 20% coinsurance of the total cost for professionally administered Part B Drugs. 20% coinsurance of the total cost for Part B Drugs. 20% coinsurance of the total cost for Part B Drugs. Chiropractic Services Medicare Blue Choice Plan 4 $20 copay per visit, for manual manipulation of the spine only, according to Medicare guidelines. Medicare Blue Choice Plan 5 $20 copay per visit, for manual manipulation of the spine only, according to Medicare guidelines. $20 copay per visit, for manual manipulation of the spine only, according to Medicare guidelines. $20 copay per visit, for manual manipulation of the spine only, according to Medicare guidelines. Dental Medicare Blue Choice Plan 4 $20 copay, when related to an accidental injury to sound, natural teeth. Medicare Blue Choice Plan 5 $40 copay, when related to an accidental injury to sound, natural teeth. $30 copay, when related to an accidental injury to sound, natural teeth. $30 copay, when related to an accidental injury to sound, natural teeth. Rochester Institute of Technology 6 Medicare-Eligible Plans Rochester Area

7 Diabetic Supplies Medicare Blue Choice Plan 4 $10 copay for 30 day supply from preferred vendor. Medicare Blue Choice Plan 5 $10 copay for 30-day supply from preferred vendor. Preferred Brand Diabetic Test Strips covered in full (Precision, OneTouch and Freestyle brands). Non preferred brand diabetic test strips are not covered without a prior authorization. Other diabetic supplies 10% coinsurance. Preferred Brand Diabetic Test Strips covered in full (Precision, OneTouch and Freestyle brands). Non preferred brand diabetic test strips are not covered without a prior authorization. Other diabetic supplies 10% coinsurance. Durable Medical Equipment (DME) Medicare Blue Choice Plan 4 Covered at 80% with no deductible at network providers. Medicare Blue Choice Plan 5 Covered at 80% with no deductible at network providers. Covered at 80% with no deductible at network providers. Covered at 80% with no deductible at network providers. Emergency Care Medicare Blue Choice Plan 4 $65 copay; waived if admitted and hospital copay would apply. Medicare Blue Choice Plan 5 $75 copay; waived if admitted and hospital copay would apply. $75 copay; waived if admitted and hospital copay would apply. $75 copay; waived if admitted and hospital copay would apply. Rochester Institute of Technology 7 Medicare-Eligible Plans Rochester Area

8 Eye Exams and Eyewear Medicare Blue Choice Plan 4 $20 copay for routine eye exams, once per year. $100 material allowance for eyeglasses and contact lenses every year, including a 25% discount at participating providers. Eyeglasses covered in full after cataract surgery. Glaucoma screening covered in full. Medicare Blue Choice Plan 5 $50 copay for routine eye exams, once per year. $100 material allowance for eyeglasses and contact lenses every year, including a 25% discount at participating providers. Eyeglasses covered in full after cataract surgery. Glaucoma screening covered in full. $30 copay for routine eye exams, once per year. $100 material allowance for eyeglasses and contact lenses every two years. 20% coinsurance for one pair of eyeglasses after cataract surgery. $30 copay for routine eye exams, once per year. $100 material allowance for eyeglasses and contact lenses every two years. 20% coinsurance for one pair of eyeglasses cataract surgery. Rochester Institute of Technology 8 Medicare-Eligible Plans Rochester Area

9 Health and Wellness Medicare Blue Choice Plan 4 Silver&Fit membership to participating fitness facilities for $25 per year. There is a $150 annual allowance to use at nonparticipant fitness facilities. Members who prefer to exercise at home, can choose 2 at home fitness kits per year ($10 per kit) instead of the fitness facility. Medicare Blue Choice Plan 5 Silver&Fit membership to participating fitness facilities for $25 per year. There is a $150 annual allowance to use at nonparticipant fitness facilities. Members who prefer to exercise at home, can choose 2 at home fitness kits per year ($10 per kit) instead of the fitness facility. Wellness Rewards receive a $75 prepaid MasterCard for completing select preventive health services. Gift card can be obtained by submitting completed screening form (signed by provider) to MVP. The SilverSneakers Fitness Program provides free fitness center membership benefits at a participating fitness center near you, including use of equipment and other amenities, at no charge. Members also receive free health education programs and support services to help you improve or maintain your health and independence, including classes on exercise and fitness, healthier eating, improving memory, preventing falls and improving balance, skills for living with diabetes, grief support, living with a chronic condition, and more. Wellness Rewards receive a $75 prepaid MasterCard for completing select preventive health services. Gift card can be obtained by submitting completed screening form (signed by provider) to MVP. The SilverSneakers Fitness Program provides free fitness center membership benefits at a participating fitness center near you, including use of equipment and other amenities, at no charge. Members also receive free health education programs and support services to help you improve or maintain your health and independence, including classes on exercise and fitness, healthier eating, improving memory, preventing falls and improving balance, skills for living with diabetes, grief support, living with a chronic condition, and more. Hearing Evaluations & Hearing Aids Medicare Blue Choice Plan 4 $20 copay per visit for exam $300 Hearing Aid allowance every 3 years. Medicare Blue Choice Plan 5 $50 copay per visit for exam, limited to one exam per year $300 Hearing Aid allowance every 3 years. $30 copay per visit $600 Hearing Aid allowance every 3 years. Plus TruHearing Discount $30 copay per visit $600 Hearing Aid allowance every 3 years. Plus TruHearing Discount Rochester Institute of Technology 9 Medicare-Eligible Plans Rochester Area

10 Home Health Care Medicare Blue Choice Plan 4 Covered in full when medically necessary and approved in advance. Medicare Blue Choice Plan 5 Covered in full when medically necessary and approved in advance. Covered in full when medically necessary and approved in advance. Covered in full when medically necessary and approved in advance. Hospice Medicare Blue Choice Plan 4 Covered in full by Medicare. Medicare Blue Choice Plan 5 Covered in full by Medicare. Covered in full by Medicare. Covered in full by Medicare. Hospital Pre-admission Testing Medicare Blue Choice Plan 4 Covered in full. Medicare Blue Choice Plan 5 Covered in full. Covered in full. Covered in full. Hospital Services-Inpatient Medicare Blue Choice Plan 4 Unlimited days of hospital and physician care subject to the inpatient copay of $250; (Limit of 3 copays per calendar year, or $750). Medicare Blue Choice Plan 5 Unlimited days of hospital and physician care subject to the inpatient copay of $700; (Limit of 3 copays per calendar year, or $2,100). Unlimited days of hospital and physician care subject to the inpatient copay of $250; (Limit of 3 copays per calendar year, or $750). Unlimited days of hospital and physician care subject to the inpatient copay of $250; (Limit of 3 copays per calendar year, or $750). Hospital Outpatient or Ambulatory Surgical Center Medicare Blue Choice Plan 4 $50 copay Medicare Blue Choice Plan 5 $100 copay $60 copay at hospital $30 copay at surgical center $60 copay at hospital $30 copay at surgical center Rochester Institute of Technology 10 Medicare-Eligible Plans Rochester Area

11 Kidney Dialysis Medicare Blue Choice Plan 4 Covered in full Medicare Blue Choice Plan 5 20% coinsurance 20% coinsurance 20% coinsurance Laboratory & Pathology Medicare Blue Choice Plan 4 Covered in full. Medicare Blue Choice Plan 5 Covered in full. $10 copay $10 copay Mental Health-Inpatient Medicare Blue Choice Plan 4 Unlimited days of hospital and physician care subject to the inpatient copay of $250; (Limit of 3 copays per calendar year, or $750). Medicare Blue Choice Plan 5 Unlimited days of hospital and physician care subject to the inpatient copay of $600; (Limit of 3 copays per calendar year, or $1,800). Unlimited days of hospital and physician care subject to the inpatient copay of $250; (Limit of 3 copays per calendar year, or $750). Unlimited days of hospital and physician care subject to the inpatient copay of $250; (Limit of 3 copays per calendar year, or $750). Mental Health-Outpatient Medicare Blue Choice Plan 4 20% coinsurance. No maximum number of visits. Medicare Blue Choice Plan 5 20% coinsurance. No maximum number of visits. Covered with $30 copay. No maximum number of visits. Covered with $30 copay. No maximum number of visits. MRI, PET, CAT Scans Medicare Blue Choice Plan 4 $20 copay Medicare Blue Choice Plan 5 $100 copay $60 copay $60 copay Rochester Institute of Technology 11 Medicare-Eligible Plans Rochester Area

12 Occupational Therapy Medicare Blue Choice Plan 4 $20 copay per visit. Medicare Blue Choice Plan 5 $40 copay per visit. $30 copay per visit, maximum payment of $1,940 per year. $30 copay per visit, maximum payment of $1,940 per year. Out of Area Coverage Medicare Blue Choice Plan 4 Coverage provided worldwide; urgent or emergent care is covered as if you are in-network. Routine care can be provided as an out of network benefit with no referrals. The out of network benefit covers routine care when you are outside the plan service area for up to six months. There is no deductible and you pay 20% coinsurance for covered services and the plan pays 80%, with a maximum coverage amount of $5,000. In other words, a maximum of $6,250 of out of network services are covered per year (i.e., you pay $1,250, the plan pays $5,000). Medicare Blue Choice Plan 5 Coverage provided worldwide; urgent or emergent care is covered as if you are in-network. Routine care can be provided as an out of network benefit with no referrals. The out of network benefit covers routine care when you are outside the plan service area for up to six months. There is no deductible and you pay 20% coinsurance for covered services and the plan pays 80%, with a maximum coverage amount of $5,000. In other words, a maximum of $6,250 of out of network services are covered per year (i.e., you pay $1,250, the plan pays $5,000). Worldwide Coverage for emergency and urgent care covered as in-network;. In addition, the out of network benefit allows you to go anywhere in the U.S. for routine and elective services. Examples of covered services out of network include: Office visits, lab, x-ray, mammograms, chiropractic care, durable medical equipment, physical, speech and occupational therapies. There is no deductible and you pay 30% coinsurance for covered services and the plan pays 70%, with a maximum coverage amount of $5,000. In other words, a maximum of $7,141 of out of network services are covered per year (i.e., you pay $2,142, the plan pays $5,000). Worldwide Coverage for emergency and urgent care covered as in-network;. In addition, the out of network benefit allows you to go anywhere in the U.S. for routine and elective services. Examples of covered services out of network include: Office visits, lab, x-ray, mammograms, chiropractic care, durable medical equipment, physical, speech and occupational therapies. There is no deductible and you pay 30% coinsurance for covered services and the plan pays 70%, with a maximum coverage amount of $5,000. In other words, a maximum of $7,141 of out of network services are covered per year (i.e., you pay $2,142, the plan pays $5,000). Rochester Institute of Technology 12 Medicare-Eligible Plans Rochester Area

13 Physical Therapy Medicare Blue Choice Plan 4 $20 copay per visit Medicare Blue Choice Plan 5 $40 copay per visit $30 copay, max payment $1,940 for Physical Therapy and Speech Therapy combined. $30 copay, max payment $1,940 for Physical Therapy and Speech Therapy combined. Physician Visit In Office, Diagnostic (ill or injured) Medicare Blue Choice Plan 4 $20 copay for Primary Care Physician and $20 copay for Specialist visit. Medicare Blue Choice Plan 5 $25 copay for Primary Care Physician and $50 copay for Specialist visit. $15 copay for Primary Care Physician and $30 copay for Specialist visit. $15 copay for Primary Care Physician and $30 copay for Specialist visit. Physician Visits In Office, Routine Preventive Services Medicare Blue Choice Plan 4 Periodic routine physicals, annual pelvic exam, Pap Smear, periodic routine mammograms and bone density screening, colorectal screening, prostate cancer screening covered in full. Immunizations (flu, pneumococcal, Hepatitis B, and other vaccines if patient is at risk) covered in full. Medicare Blue Choice Plan 5 Periodic routine physicals, annual pelvic exam, Pap Smear, periodic routine mammograms and bone density screening, colorectal screening, prostate cancer screening covered in full. Immunizations (flu, pneumococcal, Hepatitis B, and other vaccines if patient is at risk) covered in full. Podiatry Medicare Blue Choice Plan 4 $20 copay per visit. Medicare Blue Choice Plan 5 $50 copay per visit. Annual routine physicals, annual pelvic exam, Pap Smear, and periodic routine mammograms, bone density, colorectal, prostate and cancer screenings covered in full. Pneumococcal, Influenza and ( Hepatitis B vaccinations if you are at risk) immunizations covered in full. Office visit copay may apply. Annual routine physicals, annual pelvic exam, Pap Smear, and periodic routine mammograms, bone density, colorectal, prostate and cancer screenings covered in full. Pneumococcal, Influenza and ( Hepatitis B vaccinations if you are at risk) immunizations covered in full. Office visit copay may apply. $30 copay per visit. $30 copay per visit. Rochester Institute of Technology 13 Medicare-Eligible Plans Rochester Area

14 Prescription Drugs Covered Under Medical Plan NOTE: The Medicare Blue Choice plans have a 3-tier structure, but we have put copay amounts in the other 3 tiers to make the comparison to the Preferred Gold plans easier. LOCAL RETAIL PHARMACY-Coverage for 30-Day Supply Tier Medicare Blue Choice Plan 4 Medicare Blue Choice Plan 5 Preferred Gold HMO POS Preferred Gold HMO POS Initial Coverage 1. Preferred Generics $10* $5* $0 $0 2. Generics $10 $5 $10 $10 3. Preferred Brand $30 $30 $30 $35 4. Non-Preferred Brand $50 $75 $60 50% 5. Specialty Drugs $50* $75* $60 33% 6. Select Vaccines $0** $0** $0 $0 Coverage Gap (Donut Hole) After Initial Coverage (plan plus retiree cost) = $3,700 Catastrophic Coverage Reach this level when member copays in Initial Coverage + total member payments in Coverage Gap + Rx manufacturer 50% brand discount in Coverage Gap = $4,950 Part B Drugs (do not count toward Initial Coverage or Coverage Gap limits) N/A-continue to pay copays listed above $3.30 generic and $8.25 brand greater. You will never pay more than the copay amount in the Initial Coverage stage. * = not a separate tier, included in another tier ** = generally covered under medical coverage 51% generic 40% brand $3.30 generic and $8.25 brand greater N/A-continue to pay copays listed above $3.30 generic and $8.25 brand greater. You will never pay more than the copay amount in the Initial Coverage stage. 51% generic 40% brand ($0 for Tier 1 and Tier 6) $3.30 generic and $8.25 brand greater You pay 20% You pay 20% You pay 20% You pay 20% Rochester Institute of Technology 14 Medicare-Eligible Plans Rochester Area

15 NOTE: The Medicare Blue Choice plans have a 3-tier structure, but we have put copay amounts in the other 3 tiers to make the comparison to the Preferred Gold plans easier. LOCAL RETAIL PHARMACY-Coverage for 90-Day Supply Tier Medicare Blue Choice Plan 4 Medicare Blue Choice Plan 5 Preferred Gold HMO POS Option 1 Preferred Gold HMO POS Initial Coverage 1. Preferred Generics $30* $12.50* $0 $0 2. Generics $30 $12.50 $30 $30 3. Preferred Brand $90 $75 $90 $ Non-Preferred Brand $150 $ $180 50% 5. Specialty Drugs $150* $187.50* $180 33% 6. Vaccines $0** $0** $0 $0 Coverage Gap (Donut Hole) After Initial Coverage (plan plus retiree cost) = $3,700 Catastrophic Coverage Reach this level when member copays in Initial Coverage + total member payments in Coverage Gap + Rx manufacturer 50% brand discount in Coverage Gap = $4,950 Part B Drugs (do not count toward Initial Coverage or Coverage Gap limits) N/A $3.30 generic and $8.25 brand greater. You will never pay more than the copay amount in the Initial Coverage stage. * = not a separate tier, included in another tier ** = generally covered under medical coverage 51% generic 40% brand $3.30 generic and $8.25 brand greater N/A $3.30 generic and $8.25 brand greater. You will never pay more than the copay amount in the Initial Coverage stage. 51% generic 40% brand ($0 for Tier 1 and Tier 6) $3.30 generic and $8.25 brand greater You pay 20% You pay 20% You pay 20% You pay 20% Rochester Institute of Technology 15 Medicare-Eligible Plans Rochester Area

16 NOTE: The Medicare Blue Choice plans have a 3-tier structure, but we have put copay amounts in the other 3 tiers to make the comparison to the Preferred Gold plans easier. MAIL DER-Coverage for 90-Day Supply Tier Medicare Blue Choice Plan 4 Medicare Blue Choice Plan 5 Preferred Gold HMO POS Preferred Gold HMO POS Initial Coverage 1. Preferred Generics $30* $12.50* $0 $0 2. Generics $30 $12.50 $20 $20 3. Preferred Brand $90 $75 $60 $70 4. Non-Preferred Brand $150 $ $120 50% 5. Specialty Drugs $150* $187.50* $120 33% 6. Vaccines $0** $0** $0 $0 Coverage Gap (Donut Hole) After Initial Coverage (plan plus retiree cost) = $3,700 Catastrophic Coverage Reach this level when member copays in Initial Coverage + total member payments in Coverage Gap + Rx manufacturer 50% brand discount in Coverage Gap = $4,950 Part B Drugs (do not count toward Initial Coverage or Coverage Gap limits) N/A $3.30 generic and $8.25 brand greater. You will never pay more than the copay amount in the Initial Coverage stage. * = not a separate tier, included in another tier ** = covered under medical coverage 51% generic 40% brand $3.30 generic and $8.25 brand greater N/A $3.30 generic and $8.25 brand greater. You will never pay more than the copay amount in the Initial Coverage stage. 51% generic 40% brand ($0 for Tier 1 and Tier 6) $3.30 generic and $8.25 brand whichever is greater You pay 20% You pay 20% You pay 20% You pay 20% Rochester Institute of Technology 16 Medicare-Eligible Plans Rochester Area

17 Private Duty Nursing Medicare Blue Choice Plan 4 No coverage Medicare Blue Choice Plan 5 No coverage No coverage No coverage Prosthetics (External) and Orthopedic Braces and Supports Medicare Blue Choice Plan 4 Covered at 80% with no deductible at network providers. Medicare Blue Choice Plan 5 Covered at 80% with no deductible at network providers. Covered at 80% with no deductible at network providers. Covered at 80% with no deductible at network providers. Prosthetics (Internal) Medicare Blue Choice Plan 4 Covered in full with no deductible at network providers. Medicare Blue Choice Plan 5 Covered in full with no deductible at network providers. Radiation Therapy Medicare Blue Choice Plan 4 $20 copay per visit. Medicare Blue Choice Plan 5 $50 copay per visit. Covered in full with no deductible at network providers. Covered in full with no deductible at network providers. 20% coinsurance 20% coinsurance Respiratory Therapy Medicare Blue Choice Plan 4 $20 copay per visit. Medicare Blue Choice Plan 5 $40 copay per visit. $30 copay per visit. $30 copay per visit. Rochester Institute of Technology 17 Medicare-Eligible Plans Rochester Area

18 Skilled Nursing Facility Medicare Blue Choice Plan 4 Days 1-20: Covered in full. Days : Covered at 50%. Medicare Blue Choice Plan 5 Days 1-20: Covered in full. Days : Covered at 50%. Speech Therapy Medicare Blue Choice Plan 4 $20 copay Medicare Blue Choice Plan 5 $40 copay Telemedicine Medicare Blue Choice Plan 4 $20 copay Medicare Blue Choice Plan 5 $25 copay Days 1-20: Covered in full. Days : $160 per day Days 1-20: Covered in full. Days : $160 per day $30 copay, max payment $1,940 for Physical Therapy and Speech Therapy combined. $30 copay, max payment $1,940 for Physical Therapy and Speech Therapy combined. $15 copay for medical issues $30 copay for behavioral health issues $15 copay for medical issues $30 copay for behavioral health issues Travel Benefit Medicare Blue Choice Plan 4 Refer to Out of Area Coverage Medicare Blue Choice Plan 5 Refer to Out of Area Coverage Urgent Care Medicare Blue Choice Plan 4 $20 copay Medicare Blue Choice Plan 5 $50 copay Refer to Out of Area Coverage Refer to Out of Area Coverage $30 copay worldwide $30 copay worldwide Rochester Institute of Technology 18 Medicare-Eligible Plans Rochester Area

19 X-Ray-Diagnostic Medicare Blue Choice Plan 4 $20 copay Medicare Blue Choice Plan 5 $50 copay $30 copay $30 copay Rochester Institute of Technology 19 Medicare-Eligible Plans Rochester Area