2015 Medicare Advantage Plan Details |
---|
Medicare Plan Name: | GuildNet Gold (HMO-POS SNP) |
Location: | Nassau, New York Click to see other locations |
Plan ID: | H6864 - 001 - 0 Click to see other plans |
Member Services: | 1-800-815-0000 TTY users 1-800-662-1220 |
— 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 |
Email a copy of the GuildNet Gold (HMO-POS SNP) benefit details
|
— Medicare Plan Features — |
Monthly Premium: | $0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below) |
Annual Deductible: | $0 for people who qualify for both Medicare and Medicaid. |
Annual Initial Coverage Limit (ICL): | $2,960 |
Health Plan Type: | Local HMO |
Special Needs Plan (SNP) Eligibility Requirement: | Dual-Eligible |
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount |
Total Number of Formulary Drugs: | 3,443 drugs | Browse the GuildNet Gold (HMO-POS SNP) Formulary |
This plan has 5 drug tiers.
See cost-sharing for all pharmacies and tiers.
|
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
• Number of Drugs per Tier: | 215 | 2030 | 584 | 270 | 344 |
Plan's Pharmacy Search: | http://www.LighthouseGuild.org |
Plan Offers Mail Order? | Yes |
Number of Members enrolled in this plan in Nassau, New York: | 92 members |
Number of Members enrolled in this plan in (H6864 - 001): | 654 members |
Plan’s Summary Star Rating: | Insufficient data to rate this plan. |
• Customer Service Rating: | Insufficient data to rate this plan. |
• Member Experience Rating: | Insufficient data to rate this plan. |
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. |
— Plan Premium Details — |
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Base Premium | Part D Supplemental Premium |
$36.90 | $0.00 | $36.90 | $0.00 |
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 | $9.20 | $18.40 | $27.70 |
Total Monthly Premium with LIS (Parts C & D): | $0.00 | $9.20 | $18.40 | $27.70 |
— Plan Health Benefits — |
** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$0 per month. |
This plan does not have a deductible. |
This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs). |
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 some services depending on your level of [insert State Medicaid plan name] eligibility. |
Your yearly limit(s) in this plan: |
- $3 400 for services you receive from in-network providers.
|
- $3 400 for services you receive from any provider.
|
Your limit for services received from in-network providers will count toward this limit. |
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. |
** Doctor and Hospital Choice ** |
Acupuncture and Other Alternative Therapies |
Not covered |
** Extra Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs1:- In-network: You pay nothing
|
Other Part B drugs1:- In-network: You pay nothing
|
Our plan does not have a deductible for Part D prescription drugs. |
You pay the following:
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Standard Retail Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | 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.
| 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.
| 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.
| Tier 2 (Non-Preferred Generic) | 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.
| 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.
| 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.
| Tier 3 (Preferred Brand) | 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.
| 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.
| 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.
| Tier 4 (Non-Preferred Brand) | 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.
| 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.
| 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.
| Tier 5 (Specialty Tier) | 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.
| 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.
| 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.
|
|
Standard Mail Order Cost-SharingTier | Three-month supply |
---|
Tier 1 (Preferred Generic) | 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.
| Tier 2 (Non-Preferred Generic) | 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.
| Tier 3 (Preferred Brand) | 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.
| Tier 4 (Non-Preferred Brand) | 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.
| Tier 5 (Specialty Tier) | 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.
|
|
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.
|
You pay nothing |
** Important Information ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$0 per month. |
This plan does not have a deductible. |
This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs). |
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 some services depending on your level of [insert State Medicaid plan name] eligibility. |
Your yearly limit(s) in this plan: |
- $3 400 for services you receive from in-network providers.
|
- $3 400 for services you receive from any provider.
|
Your limit for services received from in-network providers will count toward this limit. |
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. |
** Outpatient Care and Services ** |
Acupuncture and Other Alternative Therapies |
Not covered |
Ambulance Services |
- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Chiropractic Care |
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Dental Services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):- In-network: You pay nothing
|
Diabetes Supplies and Services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans):- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Diagnostic tests and procedures:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Lab services:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Outpatient x-rays:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Doctor’s Office Visits |
Primary care physician visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Specialist visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Emergency Care |
You pay nothing |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Hearing Services |
Exam to diagnose and treat hearing and balance issues:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Home Health Care |
- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
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. |
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. |
- In-network: You pay nothing
|
Outpatient group therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Outpatient individual therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Outpatient Rehabilitation Services |
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Occupational therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Physical therapy and speech and language therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Outpatient Substance Abuse |
Group therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Individual therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Outpatient Surgery |
Ambulatory surgical center:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Outpatient hospital:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Over-the-Counter Items |
Please visit our website to see our list of covered over-the-counter items. |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Renal Dialysis |
- In-network: You pay nothing
|
Transportation |
Not covered |
Urgently Needed Care |
You pay nothing |
Vision Services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):- In-network: You pay nothing
|
Routine eye exam:- In-network: You pay nothing. You are covered for up to 1 visit(s) every year.
|
Contact lenses:- In-network: You pay nothing. You are covered for up to 52 every year.
|
Eyeglasses (frames and lenses):- In-network: You pay nothing. You are covered for up to 1 every year.
|
Eyeglasses or contact lenses after cataract surgery:- In-network: You pay nothing
|
Our plan pays up to $275 every year for contact lenses and eyeglasses (frames and lenses) from an in-network provider. |
** Hospice ** |
Hospice |
You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. |
** Preventive Care ** |
Preventive Care |
- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
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
Any additional preventive services approved by Medicare during the contract year will be covered. |
Annual physical exam:- In-network: You pay nothing
|
** Inpatient Care ** |
Inpatient Hospital Care |
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. |
- In-network: You pay nothing
|
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |
Skilled Nursing Facility (SNF) |
Our plan covers up to 100 days in a SNF. |
- In-network: You pay nothing
|
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs1:- In-network: You pay nothing
|
Other Part B drugs1:- In-network: You pay nothing
|
Our plan does not have a deductible for Part D prescription drugs. |
You pay the following:
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Standard Retail Cost-SharingTier | One-month supply | Two-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | 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.
| 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.
| 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.
| Tier 2 (Non-Preferred Generic) | 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.
| 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.
| 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.
| Tier 3 (Preferred Brand) | 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.
| 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.
| 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.
| Tier 4 (Non-Preferred Brand) | 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.
| 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.
| 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.
| Tier 5 (Specialty Tier) | 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.
| 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.
| 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.
|
|
Standard Mail Order Cost-SharingTier | Three-month supply |
---|
Tier 1 (Preferred Generic) | 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.
| Tier 2 (Non-Preferred Generic) | 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.
| Tier 3 (Preferred Brand) | 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.
| Tier 4 (Non-Preferred Brand) | 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.
| Tier 5 (Specialty Tier) | 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.
|
|
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.
|
You pay nothing |
** Outpatient Care ** |
Diabetes Supplies and Services |
Diabetes monitoring supplies:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Diabetes self-management training:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Therapeutic shoes or inserts:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Hearing Services |
Exam to diagnose and treat hearing and balance issues:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Individual therapy visit:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |