2015 Summary of Benefits Michigan: H5475 Plan 001. Meridian Advantage Plan (HMO SNP)

Transcription

1 2015 Summary of s Michigan: H5475 Plan 001 Meridian Advantage Plan (HMO SNP) January 1, 2015 December 31, 2015 Michigan: Barry, Genesee, Kalamazoo, Kent, Macomb, Muskegon, Oakland, Ottawa, Saginaw and Wayne Counties Ohio: Lucas County

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3 Summary of s January 1, December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Meridian Advantage Plan of Michigan (HMO SNP)). Tips for comparing your Medicare choices This Summary of s booklet gives you a summary of what Meridian Advantage Plan of Michigan (HMO SNP) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of s booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Sections in this booklet Things to Know About Meridian Advantage Plan of Michigan (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital s Prescription Drug s This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at (TTY 711).

4 Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我 们 提 供 免 费 的 翻 译 服 务, 帮 助 您 解 答 关 于 健 康 或 药 物 保 险 的 任 何 疑 问 如 果 您 需 要 此 翻 译 服 务, 请 致 电 我 们 的 中 文 工 作 人 员 很 乐 意 帮 助 您 这 是 一 项 免 费 服 务 Chinese Cantonese: 您 對 我 們 的 健 康 或 藥 物 保 險 可 能 存 有 疑 問, 為 此 我 們 提 供 免 費 的 翻 譯 服 務 如 需 翻 譯 服 務, 請 致 電 我 們 講 中 文 的 人 員 將 樂 意 為 您 提 供 幫 助 這 是 一 項 免 費 服 務 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. Arabic: األدوية جدول أو بالصحة تتعلق أسئلة أي عن لإلجابة المجانية الفوري المترجم خدمات نقدم إننا للحصول.لدينا يتحدث ما شخص سيقوم على بنا االتصال سوى عليك ليس فوري مترجم على العربية

5 . مجانية خدمةھذه.بمساعدتك Hindi 1 : हम र व स य य दव क य जन क ब र म आपक ककस भ प रन क जव ब द न क लए हम र प स म त द भ षय स व ए उ पध ह. एक द भ षय प र त करन क लए, बस हम पर फ न कर. क ई यक तत ज हहद ब त ह आपक मदद कर सकत ह. यह एक म त स व ह. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer Ta usługa jest bezpłatna. Japanese: 当 社 の 健 康 健 康 保 険 と 薬 品 処 方 薬 プランに 関 するご 質 問 にお 答 えするため に 無 料 の 通 訳 サービスがありますございます 通 訳 をご 用 命 になるには 電 話 ください 日 本 語 を 話 す 人 者 が 支 援 いたします これは 無 料 のサー ビスです

6 Things to Know About Meridian Advantage Plan of Michigan (HMO SNP) Hours of Operation You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. Meridian Advantage Plan of Michigan (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free (TTY 711). If you are not a member of this plan, call toll-free (TTY 711). Our website: Who can join? To join Meridian Advantage Plan of Michigan (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and either Michigan or Ohio Medicaid, and live in our service area. Our service area includes the following counties in Michigan: Barry, Genesee, Kalamazoo, Kent, Macomb, Muskegon, Oakland, Ottawa, Saginaw, and Wayne; and Ohio: Lucas. Which doctors, hospitals, and pharmacies can I use? Meridian Advantage Plan of Michigan (HMO SNP) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider and pharmacy directory at our website ( Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? The amount you pay for drugs depends on the drug you are taking and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage.

7 Summary of s January 1, December 31, 2015 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the $0 per month. monthly premium? How much is the This plan does not have a deductible. deductible? This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs). Is there any limit on how much I will pay for my covered services? This plan does not have a deductible for Part D prescription drugs. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for Medicare-covered services, depending on your level of either Michigan or Ohio Medicaid eligibility. Refer to the "Medicare & You" handbook for Medicare-covered services. For either Michigan or Ohio Medicaid -covered services, refer to the Medicaid Coverage section in this document. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. Is there a limit on how much the plan will pay? If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Meridian Advantage Plan is a Medicare Advantage Plan with a Medicare Contract and a Contract with the State Medicaid Program.

8 Summary of s January 1, December 31, 2015 Covered Medical and Hospital s Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Acupuncture and Other Not covered Alternative Therapies Ambulance 1 Chiropractic Care 1,2 Dental Services Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay nothing Preventive dental services: Cleaning (for up to 1 every six months): Dental x-ray(s) (for up to 1 every year): Fluoride treatment (for up to 1 every year): Oral exam (for up to 1 every six months): $200 plan coverage limit for comprehensive dental service Diabetes Supplies and Services Diagnostic Tests, Lab and Radiology Services, and X-Rays 1,2 Doctor's Office Visits 2 Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Diagnostic radiology services (such as MRIs, CT scans): Diagnostic tests and procedures: Lab services: Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): Primary care physician visit: Specialist visit:

9 Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Summary of s January 1, December 31, 2015 Copays listed apply to in-network providers. We cover all medically necessary durable medical equipment covered by Original Medicare. Emergency Care Foot Care (podiatry services) 2 Hearing Services 1,2 Home Health Care 1,2 Mental Health Care 1,2 If you receive emergency care at an out-of-network hospital and need inpatient care after your emergency condition is stabilized, you must return to a network hospital in order for your care to continue to be covered. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Exam to diagnose and treat hearing and balance issues: Routine hearing exam: Hearing aid fitting/evaluation: Hearing aid: Our plan pays up to $500 every year for routine hearing exams, hearing aid fitting/evaluations, and hearing aids. Prior to receiving home health services, a doctor must certify that you need home health services and will order home health services to be provided by a home health agency. You must be homebound, which means leaving home is a major effort. Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

10 Summary of s January 1, December 31, 2015 Outpatient group therapy visit: Outpatient individual therapy visit: Outpatient Rehabilitation 1,2 Outpatient Substance Abuse 1,2 Outpatient Surgery 1,2 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis Transportation Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Occupational therapy visit: Physical therapy and speech and language therapy visit: Group therapy visit: Individual therapy visit: Ambulatory surgical center: Outpatient hospital: Please visit our website to see our list of covered over-the-counter items. $25 monthly allowance for approved OTC items, unused monthly benefit does not rollover to subsequent months. Prosthetic devices: Related medical supplies: Meridian Advantage Plan will cover 10 round trips for non-emergent medical and dental appointments. Additional transportation coverage may be available through your Medicaid provider. Urgent Care Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Routine eye exam: Contact lenses: Eyeglasses (frames and lenses): Eyeglass frames: Eyeglass lenses: Eyeglasses or contact lenses after cataract surgery: Our plan pays up to $195 every year for eyewear.

11 Preventive Care Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Hospice Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam: for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. When you enroll in a Medicare-certified hospice program, your hospice services and your Part A and Part B services related to your terminal condition are paid for by Original Medicare, not Meridian Advantage Plan. Inpatient Care Inpatient Hospital Care 1,2 The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay.

12 Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1,2 Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. For inpatient mental health care, see the "Mental Health Care" section of this booklet. Our plan covers up to 100 days in a SNF. Prescription Drug s How much do I pay? For Part B drugs such as chemotherapy drugs 1 : Other Part B drugs 1 : Initial Coverage Our plan does not have a deductible for Part D prescription drugs. Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.20 copay; or $2.65 copay For all other drugs, either: $0 copay; or $3.60 copay; or $6.60 copay Catastrophic Coverage You may get your drugs at network retail pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.

13 Summary of s January 1, December 31, 2015 A Medicare Advantage Prescription Drug (MAPD) Special Needs Plan (SNP) is available to anyone receiving Medical Assistance from both the State (Medicaid) and Medicare. This means, as a member of our plan, benefits covered by both Medicare and Medicaid are covered first by Medicare (Meridian Advantage Plan of Michigan), and second by Medicaid. In other words, for benefits covered by both Medicare and Medicaid, Meridian Advantage Plan will pay first and Medicaid will pay second. If you qualify for this Special Needs Plan, you are not subject to cost sharing for Medicare Parts A and B services when the state is responsible for those amounts. Please contact Member Services at the phone number listed below if you believe you have received a bill in error. Once you have reached your benefit limit for a Medicare-covered service, you might be able to continue receiving the benefit through the Medicaid program. In some cases, Medicaid will pay for a service or costs that Medicare does not. For Medicare covered services, there is no Medicaid copay. However, for services only covered under Medicaid, co-pays may apply. If you have questions about how your benefits are coordinated between Medicare and Medicaid, please contact: Meridian Advantage of MichiganPlan Member Services at (TTY users should call 711), Monday through Sunday from 8am to 8pm. The Michigan Department of Community Health at (TTY users should call 711), visit their website at or write to them at Capital View Building, 201 Townsend Street, Lansing, MI The Ohio Department of Medicaid at (TTY users should call 711), visit their website at or write to them at 50 West Town Street, Suite 400, Columbus, OH The information below is a summary of the benefits offered through your Medicare and Medicaid coverage.

14 Michigan Medicaid Coverage Category Coverage Meridian Advantage Plan (HMO SNP) s Ambulance Covered for Emergency Transportation Chiropractic Care $1 - Covered Dental Services $3 - Covered Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay nothing Preventive dental services: Cleaning (for up to 1 every six months): $0 Dental x-ray(s) (for up to 1 every year): $0 Fluoride treatment (for up to 1 every year): Oral exam (for up to 1 every six months): Doctor s Office Visits $2 - Covered Durable Medical Equipment - Covered Emergency Care $3 Copayment only applies to non-emergency services in the emergency room. There is no co-payment for true emergency services. Foot Care $2 - Covered Hearing Services $3 for beneficiaries under 21; not a covered benefit for beneficiaries age 21 and older $200 plan coverage limit for comprehensive dental service Primary care physician visit: Specialist visit: Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: Exam to diagnose and treat hearing and balance issues: Routine hearing exam: Hearing aid fitting/evaluation: Hearing aid: Our plan pays up to $500 every year for routine hearing exams, hearing aid fitting/evaluations, and hearing aids.

15 Home Health Care - Covered Mental Health Care $ 0 - Up to 20 outpatient visits per calendar year, then provided through the Community Mental Health Services Program Outpatient Rehabilitation Prosthetic Devices Transportation Urgent Care Vision Services - Covered - Covered Covered benefit to medical and dental appointments with limitations. $2 - Covered $2 - Covered Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Outpatient group therapy visit: Outpatient individual therapy visit: $0 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $0 Occupational therapy visit: Physical therapy and speech and language therapy visit: Prosthetic devices: Related medical supplies: $0 - Meridian Advantage Plan will cover 10 round trips for non-emergent medical and dental appointments. Additional transportation coverage may be available through your Medicaid provider. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Routine eye exam: Contact lenses: Eyeglasses (frames and lenses): Eyeglass frames: Eyeglass lenses: Eyeglasses or contact lenses after cataract surgery: Our plan pays up to $195 every year for

16 Hospice - Covered Inpatient Hospital Care $50 - Day 1 Inpatient Hospital Stay Pharmacy Generic Drug: $1 Brand Name Drug: $3 eyewear. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. Our plan does not have a deductible for Part D prescription drugs. Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.20 copay; or $2.65 copay For all other drugs, either: $0 copay; or $3.60 copay; or $6.60 copay

17 Ohio Medicaid Category Coverage Meridian Advantage Plan (HMO SNP) s Ambulance - Covered Chiropractic Care - 15 visits every 12 months for adults older than age 21 Dental Services Checkup and Cleaning: $0 Once per year Fillings, Extractions, Crowns, and Root Canals: $3 Services based upon medical necessity, May require prior authorization Dentures: $3 copay prior Authorization necessary Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0 Preventive dental services: Cleaning (for up to 1 every six months): $0 Dental x-ray(s) (for up to 1 every year): $0 Fluoride treatment (for up to 1 every year): Oral exam (for up to 1 every six months): $0 Doctor s Office Visits Durable Medical Equipment Emergency Care Foot Care Hearing Services - Up to 24 visits every 12 months, additional visits for specified conditions - May Require Prior Authorization $3 for nonemergency services performed in the emergency room - One long term care facility visit per month, one nail debridement per 60 days - Hearing aid requires prior authorization $200 plan coverage limit for comprehensive dental service Primary care physician visit: Specialist visit: Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: Exam to diagnose and treat hearing and balance issues: Routine hearing exam: Hearing aid fitting/evaluation: Hearing aid: Our plan pays up to $500 every year for routine hearing exams, hearing aid fitting/evaluations, and hearing aids.

18 Home Health Care - Prior Authorization Required Mental Health Care Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Outpatient group therapy visit: Outpatient individual therapy visit: $0 Outpatient Rehabilitation Physical or Occupational Cardiac (heart) rehab services (for a Therapy- $0 maximum of 2 one-hour sessions per day for ; 30 visits combined up to 36 sessions up to 36 weeks): $0 every 12 months Prosthetic Devices Transportation Vision Services Hospice Speech/Language Pathology Services- ; 30 visits combined every 12 months - Prior Authorization Required - Covered Age 21-59: One exam and eyeglasses every 24 months Younger than 21 or Older than 59: One exam and eyeglasses every 12 months Individuals older than 21: $2 for exam, $1 for eyeglasses - Covered Occupational therapy visit: Physical therapy and speech and language therapy visit: Prosthetic devices: Related medical supplies: Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Routine eye exam: Contact lenses: Eyeglasses (frames and lenses): Eyeglass frames: Eyeglass lenses: Eyeglasses or contact lenses after cataract surgery: Our plan pays up to $195 every year for eyewear.

19 Inpatient Hospital Care Prescriptions - Covered $3 for prescription drugs requiring prior authorization, $2 for most name brand drugs, for hospice consumers and medications for emergency services and family planning The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. Our plan does not have a deductible for Part D prescription drugs. Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.20 copay; or $2.65 copay For all other drugs, either: $0 copay; or $3.60 copay; or $6.60 copay