In-network | |
---|---|
住院承保1 | $0 共付额 |
门诊医院承保:1 | $0 共付额,在医院内进行的门诊手术 |
门诊手术中心1 | $0 共付额,门诊手术中心的门诊手术 |
初级护理提供者拜访 | $0 共付额 |
专科医生看诊2 | $0 共付额 |
预防性护理 | $0 copay |
急救护理 | $150 共付额 如果您在 24 小时内住院,无需支付急救护理共付额。 |
紧急需要的服务 | $0 共付额 |
Plan Details
Providence Medicare Sycamore + Rx (HMO)
Overview
Monthly Premium |
$0 |
Annual Deductible |
$0 |
Maximum Out-of-Pocket |
$400 In-network |
处方药承保范围
牙科服务每 6 个月为 350 美元
视力检查为 0 美元
助听器共付额 + 0 美元检查费
健身房会员
Extra Help
Extra Help, also known as a Part D Low-Income Subsidy, or LIS, is a federal program that helps lower prescription costs and Part D (prescription) costs for Medicare Advantage members. Learn more about Extra Help by connecting with one of our team members who can help walk you through how the program works.
Learn more提供商网络
Search the integrated network to find in-network providers or pharmacies. When searching, please select your plan as your provider network.
Search the networkImportant information about this plan
This plan is available in Orange County in California.
Does not include any Part B premium you may have to pay. You must continue to pay your Medicare Part B premium.
- Find out if you qualify for Extra Help with your premiums
- Medical appeals, determination, and grievance processes
For more information about Providence Medicare Advantage Plans, please contact the sales team.
This information is available in a different format, including audio CDs. If you need plan information in another format, please call Customer Service at 503-574-8000 or 1-800-603-2340 (TTY: 711). Service is available between 8 a.m. to 8 p.m. (Pacific Time) 7 days a week from October 1st through March 31st and Monday - Friday, from April 1st through September 30th.
有关这些福利的重要说明
我们的计划会员享有原始 Medicare 承保的所有福利,另外,作为普罗维登斯 Medicare Advantage 计划的会员。
福利概要
-
Benefits
-
Diagnostic Services + Labs & Imaging1
In-network 诊断放射学服务(例如,MRI、超声、CT 扫描) $0 共付额 放射治疗服务 $50 共付额 门诊 X 射线检查 $0 共付额 诊断测试和程序 $0 共付额 实验室服务 $0 共付额 -
Hearing Services
In-network Medicare 承保2 $0 共付额 常规检查 $0 共付额 助听器 每台助听器的共付额为 499 美元 - 标准
每台助听器的共付额为 699 美元 - 预付
每台助听器的共付额为 999 美元 - 保费 -
Dental Services
In-network Medicare 承保2 $0 共付额 Flex 牙科诊疗卡 $350 every 6 months for any dental services of your choosing -
Vision Services
In-network Medicare 承保2 $0 共付额
$0 共付额,青光眼筛查常规检查 每 日历年 进行一次常规视力检查(包括屈光检查),无需共同保险或共付额。 Medicare 承保的眼镜 $0 共付额,一副 Medicare 承保的眼镜或每次白内障手术后的隐形眼镜 -
Mental Health Services1
In-network 住院治疗 $0 共付额 门诊个人和团体治疗访视 $0 共付额 -
Skilled Nursing Facility1
In-network 专业护理机构 1-20 天 $0 共付额
$100 共付额,21-100 天每天 -
Physical Therapy1
In-network 物理疗法 $0 共付额 -
Ambulance1
In-network 救护车 $100 共付额 -
Medicare Part B Drugs1
In-network Medicare B 部分药物 0% - 20% of the total cost
(Insulin cost share up to $35 per month) -
替代性护理 1
网络内 替代护理(脊椎推拿、针灸和自然疗法服务) Medicare 承保的脊柱推拿或针灸:0 美元共付额(有事先授权) -
Meal Delivery Program
In-network 餐饮配送计划
(仅限出院后)$0 共付额,14 天每天 2 餐,在符合条件住院治疗后 -
Over-the-Counter Items
In-network 非处方商品 Not covered -
Personal Emergency Response System
In-network 个人应急响应系统 (PERS) 不承保 -
健身计划
网络内 健康计划 $0 共付额,在参与计划的健身俱乐部每月健身会籍 -
Wig
In-network 假发 因化疗导致脱发而购买一顶假发,无需共同保险或共付额。
2 服务可能需要您的医生推荐。
处方药
-
Prescription Drug Deductible
年度免赔额
由于本计划没有免赔额,此付款阶段不适用于您。 -
Preferred Retail + Mail Order Cost Sharing
Up to 30 days Up to 60 days Up to 100 days 1 级(首选仿制药) $0 共付额 $0 共付额 $0 共付额 2 级 ( 仿制药) $0 共付额 $0 共付额 $0 共付额 3 级(首选品牌药) $40 共付额
($35 共付额,D 部分承保胰岛素)$80 共付额
($70 共付额,D 部分承保胰岛素)首选零售商 $120 共付额
($105 共付额,D 部分承保胰岛素,邮购订单 $95 共付额)第 4 级(非首选药物) $100 共付额 $200 共付额 $300 共付额 第 5 级(特药层级) 总额的 33% 不承保 不承保 -
Standard Retail Cost Sharing
Up to 30 days Up to 60 days Up to 100 days Tier 1 (Preferred Generic) $16 copay $32 copay $48 copay Tier 2 (Generic) $20 copay $40 copay $60 copay Tier 3 (Preferred Brand) $47 copay
($35 copay for Part D covered insulin)$94 copay
($70 copay for Part D covered insulin)$141 copay
($105 copay for Part D covered insulin)Tier 4 (Non-Preferred Drug) $100 copay $200 copay $300 copay Tier 5 (Specialty Tier) 33% of total Not covered Not covered -
Medicare Part D benefit stages
第 1 阶段:此阶段仅适用于具有 D 部分免赔额的计划。您将保持在此阶段,直到达到 3 级、4 级和 5 级药物的 D 部分免赔额。
第 2 阶段:您将保持在此阶段,直到自付费用达到 2,100 美元,然后进入第 3 阶段。
第 3 阶段:也称为重大伤病承保。在此阶段,您无需支付承保 D 部分药物的费用。
-
Participating Pharmacies
处方集和/或药房网络随时可能发生变化。您将在必要时收到通知。
关于疫苗费用的重要信息 - 本计划承保大部分 D 部分疫苗,您无需支付任何费用。有关详细信息,请联系客户服务部。
关于您支付多少胰岛素费用的重要信息 — 对于本计划所承保的每种胰岛素产品,您一个月药量的费用不会超过 35 美元或 25% 共同保险,无论其属于哪个成本分摊级别。