2013 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Freedom Blue PPO HD Rx (PPO) | ||||
Location: | Potter, Pennsylvania Click to see other locations | ||||
Plan ID: | H3916 - 020 - 0 Click to see other plans | ||||
Member Services: | 1-800-550-8722 TTY users 1-888-422-1226 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Freedom Blue PPO HD Rx (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $14.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 | ||||
Annual Rx Initial Coverage Limit (ICL): | $2,970 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $5,000 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 5,246 drugs | Browse the Freedom Blue PPO HD Rx (PPO) Formulary | |||
This plan has 4 drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $10.00 | $45.00 | $95.00 | 33% | |
• Number of Drugs per Tier: | 2262 | 629 | 2001 | 385 | |
Plan's Pharmacy Search: | http://www.highmarkblueshield.com | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in (H3916 - 020): | 5,321 members | ||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
• Customer Service Rating: | 4 out of 5 Stars. | ||||
• Member Experience Rating: | 5 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$14 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
Some physicians providers and suppliers that are out of a plan’s network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment " your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare "limiting charge" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.go | |||||
Highmark Inc. will reduce your monthly Medicare Part B premium by up to $ 3.00. | |||||
$5 000 out-of-pocket limit for Medicare-covered services. | |||||
$1 000 annual deductible. Contact the plan for services that apply. | |||||
Any annual service category deductible may count towards the plan level deductible if there is one. | |||||
$10 000 out-of-pocket limit for Medicare-covered services. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. | |||||
Plan covers you when you travel in the U.S. or its territories. | |||||
** Extra Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
$40 copay for each one-way trip to Plan-approved location. | |||||
50% of the cost for transportation. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$14 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
Some physicians providers and suppliers that are out of a plan’s network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment " your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare "limiting charge" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.go | |||||
Highmark Inc. will reduce your monthly Medicare Part B premium by up to $ 3.00. | |||||
$5 000 out-of-pocket limit for Medicare-covered services. | |||||
$1 000 annual deductible. Contact the plan for services that apply. | |||||
Any annual service category deductible may count towards the plan level deductible if there is one. | |||||
$10 000 out-of-pocket limit for Medicare-covered services. | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. | |||||
Plan covers you when you travel in the U.S. or its territories. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
$1 400 out-of-pocket limit every stay. | |||||
10% of the cost for each Medicare-covered hospital stay | |||||
$0 copay for additional hospital days | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
30% of the cost for each hospital stay. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. | |||||
The out-of-pocket limit is covered under "Inpatient Hospital Care." | |||||
10% of the cost for each Medicare-covered hospital stay. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
30% of the cost for each hospital stay. | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For SNF stays: | |||||
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30% of the cost for each SNF stay. | |||||
Home Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered home health visits | |||||
30% of the cost for Medicare-covered home health visits | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$5 copay for each Medicare-covered primary care doctor visit. | |||||
$25 copay for each Medicare-covered specialist visit. | |||||
30% of the cost for each Medicare-covered primary care doctor visit | |||||
30% of the cost for each Medicare-covered specialist visit | |||||
Chiropractic Services | |||||
Authorization rules may apply. | |||||
$20 copay for each Medicare-covered chiropractic visit | |||||
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor. | |||||
30% of the cost for Medicare-covered chiropractic visits. | |||||
Podiatry Services | |||||
10% of the cost for each Medicare-covered podiatry visit | |||||
Medicare-covered podiatry visits are for medically-necessary foot care. | |||||
30% of the cost for Medicare-covered podiatry visits | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
10% of the cost for each Medicare-covered individual therapy visit | |||||
10% of the cost for each Medicare-covered group therapy visit | |||||
$25 copay for each Medicare-covered individual therapy visit with a psychiatrist | |||||
$25 copay for each Medicare-covered group therapy visit with a psychiatrist | |||||
15% of the cost for Medicare-covered partial hospitalization program services | |||||
30% of the cost for Medicare-covered Mental Health visits with a psychiatrist | |||||
30% of the cost for Medicare-covered Mental Health visits | |||||
30% of the cost for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
10% of the cost for Medicare-covered individual substance abuse outpatient treatment visits | |||||
10% of the cost for Medicare-covered group substance abuse outpatient treatment visits | |||||
30% of the cost Medicare-covered substance abuse outpatient treatment visits | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
15% of the cost for each Medicare-covered ambulatory surgical center visit | |||||
15% of the cost for each Medicare-covered outpatient hospital facility visit | |||||
30% of the cost for Medicare-covered outpatient hospital facility visits | |||||
30% of the cost for Medicare-covered ambulatory surgical center visits | |||||
Ambulance Services | |||||
$100 copay for Medicare-covered ambulance benefits. | |||||
$100 copay [or 30% of the cost] for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$65 copay for Medicare-covered emergency room visits | |||||
Worldwide coverage. | |||||
If you are admitted to the hospital within 3-day(s) for the same condition you pay $0 for the emergency room visit. | |||||
Urgently Needed Care | |||||
$50 copay for Medicare-covered urgently-needed-care visits | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
10% of the cost for Medicare-covered Occupational Therapy visits | |||||
10% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits | |||||
30% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits | |||||
30% of the cost for Medicare-covered Occupational Therapy visits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered durable medical equipment | |||||
0% to 50% of the cost for Medicare-covered durable medical equipment | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered prosthetic devices | |||||
50% of the cost for Medicare-covered prosthetic devices. | |||||
Diabetes Programs and Supplies | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered Diabetes self-management training | |||||
$0 copay for Medicare-covered: | |||||
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If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $5 to $25 may apply | |||||
0% of the cost for Medicare-covered Diabetes self-management training | |||||
50% of the cost for Medicare-covered Diabetes monitoring supplies | |||||
50% of the cost for Medicare-covered Therapeutic shoes or inserts | |||||
If the doctor provides you services in addition to (Diabetes Self-Management Training) separate cost sharing of 30% of the cost may apply | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered: | |||||
| |||||
0% to 10% of the cost for Medicare-covered lab services | |||||
0% to 10% of the cost for Medicare-covered diagnostic procedures and tests | |||||
10% of the cost for Medicare-covered X-rays | |||||
15% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $5 to $25 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $5 to $25 may apply | |||||
30% of the cost for Medicare-covered therapeutic radiology services | |||||
30% of the cost for Medicare-covered outpatient X-rays | |||||
30% of the cost for Medicare-covered diagnostic radiology services | |||||
0% to 30% of the cost for Medicare-covered diagnostic procedures tests and lab services | |||||
If the doctor provides you services in addition to (Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays) separate cost sharing of 30% of the cost may apply | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$0 copay for: | |||||
| |||||
30% of the cost for Medicare-covered Cardiac Rehabilitation Services | |||||
30% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services | |||||
30% of the cost for Medicare-covered Pulmonary Rehabilitation Services | |||||
Preventive Services and Wellness/Education Programs | |||||
$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. | |||||
The plan covers the following supplemental education/wellness programs: | |||||
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0% of the cost for Medicare-covered preventive services | |||||
50% of the cost for supplemental education/wellness programs | |||||
Kidney Disease and Conditions | |||||
15% of the cost for Medicare-covered renal dialysis | |||||
$0 copay for Medicare-covered kidney disease education services | |||||
0% of the cost for Medicare-covered kidney disease education services | |||||
0% to 30% of the cost for Medicare-covered renal dialysis | |||||
Outpatient Prescription Drugs | |||||
0% to 30% of the cost for Medicare Part B drugs out-of-network. | |||||
0% to 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://client.formularynavigator.com/clients/highmark/default.html on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel). | |||||
Total yearly drug costs are the total drug costs paid by both you and a Part D plan. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from Freedom Blue PPO HD Rx (PPO) for certain drugs. | |||||
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. | |||||
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. | |||||
If you request a formulary exception for a drug and Freedom Blue PPO HD Rx (PPO) approves the exception you will pay Tier 2: Preferred Brand cost sharing for that drug. | |||||
$0 deductible. | |||||
You pay the following until total yearly drug costs reach $2 970: | |||||
Tier 1: Generic | |||||
Tier 2: Preferred Brand | |||||
Tier 3: Non-Preferred Brand | |||||
Tier 4: Specialty Tier | |||||
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Tier 1: Generic | |||||
Tier 2: Preferred Brand | |||||
Tier 3: Non-Preferred Brand | |||||
Tier 4: Specialty Tier | |||||
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Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed. | |||||
Tier 1: Generic | |||||
Tier 2: Preferred Brand | |||||
Tier 3: Non-Preferred Brand | |||||
Tier 4: Specialty Tier | |||||
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After your total yearly drug costs reach $2 970 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan’s costs for brand drugs and 79% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4 750. | |||||
After your yearly out-of-pocket drug costs reach $4 750 you pay the greater of:
| |||||
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from Freedom Blue PPO HD Rx (PPO). | |||||
You will be reimbursed up to the plan’s cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 970: | |||||
Tier 1: Generic | |||||
Tier 2: Preferred Brand | |||||
Tier 3: Non-Preferred Brand | |||||
Tier 4: Specialty Tier | |||||
| |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount. | |||||
You will be reimbursed up to 21% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount. | |||||
After your yearly out-of-pocket drug costs reach $4 750 you will be reimbursed for drugs purchased out-of-network up to the plan’s cost of the drug minus your cost share which is the greater of:
| |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount. | |||||
Dental Services | |||||
Authorization rules may apply. | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
15% of the cost for Medicare-covered dental benefits | |||||
30% of the cost for Medicare-covered comprehensive dental benefits | |||||
Hearing Services | |||||
$0 copay for hearing aids. | |||||
$25 copay for Medicare-covered diagnostic hearing exams | |||||
$25 copay for up to 1 supplemental routine hearing exam(s) every year | |||||
30% of the cost for Medicare-covered diagnostic hearing exams. | |||||
30% of the cost for supplemental hearing exams. | |||||
0% of the cost for supplemental hearing aids. | |||||
The plan will pay up to $500 for all of the following services combined: Supplemental
| |||||
$500 plan coverage limit for supplemental routine hearing aids every three years. This limit applies to both in-network and out-of-network benefits. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$0 copay for
| |||||
| |||||
If the doctor provides you services in addition to eye exams separate cost sharing of $5 to $25 may apply | |||||
$100 plan coverage limit for contact lenses every two years. | |||||
$100 plan coverage limit for eye glass frames every two years. | |||||
Plan offers additional vision benefits. Contact plan for details. | |||||
0% to 30% of the cost for Medicare-covered eye exams | |||||
0% to 30% of the cost for supplemental eye exams | |||||
30% of the cost for Medicare-covered eye wear | |||||
30% of the cost for supplemental eye wear | |||||
$100 plan coverage limit for contact lenses every two years. This limit applies to both in-network and out-of-network benefits. | |||||
$100 plan coverage limit for eye glass frames every two years. This limit applies to both in-network and out-of-network benefits. | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
$40 copay for each one-way trip to Plan-approved location. | |||||
50% of the cost for transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
$1 400 out-of-pocket limit every stay. | |||||
10% of the cost for each Medicare-covered hospital stay | |||||
$0 copay for additional hospital days | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
30% of the cost for each hospital stay. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$5 copay for each Medicare-covered primary care doctor visit. | |||||
$25 copay for each Medicare-covered specialist visit. | |||||
30% of the cost for each Medicare-covered primary care doctor visit | |||||
30% of the cost for each Medicare-covered specialist visit | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
15% of the cost for each Medicare-covered ambulatory surgical center visit | |||||
15% of the cost for each Medicare-covered outpatient hospital facility visit | |||||
30% of the cost for Medicare-covered outpatient hospital facility visits | |||||
30% of the cost for Medicare-covered ambulatory surgical center visits | |||||
Ambulance Services | |||||
$100 copay for Medicare-covered ambulance benefits. | |||||
$100 copay [or 30% of the cost] for Medicare-covered ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered durable medical equipment | |||||
0% to 50% of the cost for Medicare-covered durable medical equipment | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered: | |||||
| |||||
0% to 10% of the cost for Medicare-covered lab services | |||||
0% to 10% of the cost for Medicare-covered diagnostic procedures and tests | |||||
10% of the cost for Medicare-covered X-rays | |||||
15% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $5 to $25 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $5 to $25 may apply | |||||
30% of the cost for Medicare-covered therapeutic radiology services | |||||
30% of the cost for Medicare-covered outpatient X-rays | |||||
30% of the cost for Medicare-covered diagnostic radiology services | |||||
0% to 30% of the cost for Medicare-covered diagnostic procedures tests and lab services | |||||
If the doctor provides you services in addition to (Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays) separate cost sharing of 30% of the cost may apply | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
$40 copay for each one-way trip to Plan-approved location. | |||||
50% of the cost for transportation. |