Company Brand New Day Brand New Day Brand New Day Brand New Day
Plan Name Bridges Drug Savings Bridges Extra Care Harmony Healthy Heart Drug Savings
Telephone Numbers Website
New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com
New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com
New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com
New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com
Plan Type
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with dementia.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with dementia.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic and disabling mental health conditions.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic heart failure.
Total Monthly Premium $0 Monthly Premium $28.80 Monthly Premium $28.80 Monthly Premium $0 Monthly Premium Size of Physician and Provider
Network 5001-5500 physicians and providers 5001-5500 physicians and providers 1001-1500 physicians and providers 5001-5500 physicians and providers
Doctor Visit $0 each visit $0 each visit $0 each visit $0 each visit
Specialist Visit $0 each visit $0 each visit $0 each visit $0 each visit
Out of Pocket Limit $3,400 In-Network $6,700 In-Network $6,700 In-Network $3,400 In-Network
In-patient Hospitalization period. 60 lifetime reserve days.$0 copay. 90 days each benefit 90 days each benefit period. 60 lifetime reserve days. Contact plan for more details.
90 days each benefit period. 60 lifetime reserve days. Contact plan for more details.
$0 copay. 90 days each benefit period. 60 lifetime reserve
days.
Skilled Nursing Facility 100: $148/day. 100 days each Days 1-20: $0/day. Days 21-benefit period.
100 days each benefit period.
Contact plan for more details. 100 days each benefit period. Contact plan for more details. $0 copay. 100 days each benefit period.
In-patient Mental Health $0 copay. 190-day psychiatric hospital lifetime limit. lifetime limit. Contact plan for 190-day psychiatric hospital more details.
190-day psychiatric hospital lifetime limit. Contact plan for
more details.
$ 0 copay. 190-day psychiatric hospital lifetime limit.
Outpatient Mental Health $0 each session $0 each session $0 each session $0 each session
Outpatient Hospital Services $65 - $100 each visit 0-20% of the cost each visit 0-20% of the cost each visit $0 each visit Ambulance 20% of the cost each service 20% of the cost each service 20% of the cost each service $65 each service
Emergency Room Visit $65 each visit, waived if admitted within 3-days. $65 each visit, waived if admitted within 3-days. $65 each visit, waived if admitted within 3-days. $65 each visit, waived if admitted within 3-days. Outpatient Rehabilitation
Services $0 each visit occup. & cardiac 20% each visit all others 20% of the cost for each visit. 20% of the cost for each visit. $0 each visit occup. & cardiac 20% each visit all others Durable Medical Equipment 20% of cost foritems.Medicare-covered 20% of cost forcovered items.Medicare- 20% for each item.Medicare-covered 20% for each item.Medicare-covered
Diagnostic Tests procedures/tests. $0 for $0 for diagnostic diagnostic radiology services.
$0 for diagnostic procedures/tests. $0 for diagnostic radiology services.
$0 for diagnostic procedures/tests. $0 for diagnostic radiology services.
$0 for diagnostic procedures/tests. $0 for diagnostic radiology services.
X-Rays $0 copay each X-ray $0 copay each X-ray $0 copay each X-ray $0 copay each X-ray
Lab Services $0 each lab service. 20% of the cost for therapeutic radiology. $0 each lab service. 20% of the cost for therapeutic radiology. $0 each lab service. 20% of the cost for therapeutic radiology. $0 each lab service. 20% of the cost for therapeutic radiology.
Renal Dialysis 20% of the cost 20% of the cost 20% of the cost 20% of the cost
Part B Chemotherapy Drugs 20% of the cost 20% of the cost 20% of the cost 20% of the cost
Dental Services 0-20% of the cost for covered benefits. Contact plan Medicare-for additional benefits.
$0 for Medicare-covered benefits. Contact plan for
additional benefits.
$0 for Medicare-covered benefits. Contact plan for
additional benefits.
0-20% of the cost for Medicare-covered benefits. Contact plan
for additional benefits.
Hearing Services $0 for diagnostic exams. Routine exams and hearing aids not covered.
20% for diagnostic exams. Routine exams and hearing
aids not covered.
20% for diagnostic exams. Routine exams and hearing
aids not covered.
20% for diagnostic exams. Routine exams and hearing aids
not covered.
Vision Services
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
Transportation Transportation not covered. $0 copay $0 copay Transportation not covered.
2015 Orange County HICAP
Medicare Advantage Special Needs Plans
Comparison Chart
Company Plan Name
Telephone Numbers Website
Plan Type
Total Monthly Premium Size of Physician and Provider
Network Doctor Visit Specialist Visit Out of Pocket Limit
In-patient Hospitalization
Skilled Nursing Facility
In-patient Mental Health
Outpatient Mental Health Outpatient Hospital Services
Ambulance
Emergency Room Visit Outpatient Rehabilitation
Services
Durable Medical Equipment
Diagnostic Tests
X-Rays Lab Services Renal Dialysis Part B Chemotherapy Drugs
Dental Services
Hearing Services
Vision Services
Transportation Prescription Drugs
Brand New Day Brand New Day Brand New Day Brand New Day
Healthy Heart Extra Care Hope Drug Savings In Control Drug Savings In Control Extra Care
New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com
New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com
New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com
New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic heart failure.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic and disabling mental health conditions.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with diabetes mellitus.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with diabetes mellitus. $28.80 Monthly Premium $0 Monthly Premium $0 Monthly Premium $28.80 Monthly Premium 5001-5500 physicians and
providers 1001-1500 physicians and providers 5001-5500 physicians and providers 5001-5500 physicians and providers $0 each visit $0 each visit $0 each visit $0 each visit $0 each visit $0 each visit $0 each visit $0 each visit $6,700 In-Network $3,400 In-Network $3,400 In-Network $6,700 In-Network 90 days each benefit period.
60 lifetime reserve days. Call plan for more details.
$0 copay. 90 days each benefit period. 60 lifetime reserve days.
$0 copay. 90 days each benefit period. 60 lifetime reserve
days.
90 days each benefit period. 60 lifetime reserve days. Contact plan for more details. 100 days each benefit period.
Call plan for more details. $0 copay. 100 days each benefit period. $0 copay. 100 days each benefit period. 100 days each benefit period. Contact plan for more details. 190-day psychiatric hospital
lifetime limit. Contact plan for more details.
$0 copay. 190-day psychiatric
hospital lifetime limit. $0 copay. 190-day psychiatric hospital lifetime limit.
190-day psychiatric hospital lifetime limit. Contact plan for
more details. $0 each session $0 each session $0 each session $0 each session 0-20% of the cost each visit $0 each visit $0 each visit 20% of the cost each visit 20% of the cost each service $65 each service $65 each service 20% of the cost each service
$65 each visit, waived if
admitted within 3-days. $65 each visit, waived if admitted within 3-days. $65 each visit, waived if admitted within 3-days. $65 each visit, waived if admitted within 3-days. 20% of the cost for each visit. $0 each visit occup. & cardiac 20% each visit all others $0 each visit occup. & cardiac 20% each visit all others 20% of the cost for each visit
20% for each
Medicare-covered item. 20% for each
Medicare-covered
item. 20% for each
Medicare-covered
item. 20% for each
Medicare-covered item. $0 for diagnostic
procedures/tests. $0 for diagnostic radiology services.
$0 for diagnostic procedures/tests. $0 for diagnostic radiology services.
$0 for diagnostic procedures/tests. $0 for diagnostic radiology services.
$0 for diagnostic procedures/tests. $0 for diagnostic radiology services. $0 copay each X-ray $0 copay each X-ray $0 copay each X-ray $0 copay each X-ray $0 each lab service. 20% of the
cost for therapeutic radiology. $0 each lab service. 20% of the cost for therapeutic radiology. $0 each lab service. 20% of the cost for therapeutic radiology. $0 each lab service. 20% of the cost for therapeutic radiology. 20% of the cost 20% of the cost 20% of the cost 20% of the cost 20% of the cost 20% of the cost 20% of the cost 20% of the cost $0 for Medicare-covered
benefits. Contact plan for additional benefits.
0-20% of the cost for Medicare-covered benefits. Contact plan
for additional benefits.
0-20% of the cost for Medicare-covered benefits. Contact plan
for additional benefits.
$0 for Medicare-covered
benefits. Contact plan for additional benefits. 20% for diagnostic exams.
Routine exams and hearing aids not covered.
20% for diagnostic exams. Routine exams and hearing aids
not covered.
20% for diagnostic exams. Routine exams and hearing aids
not covered.
20% for diagnostic exams. Routine exams and hearing
aids not covered. $0 copay for diagnosis and
treatment of eye conditions. Contact plan for additional
benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits. $0 copay Transportation not covered. Transportation not covered. $0 copay See separate Chart See separate Chart See separate Chart See separate Chart
2015 Orange County HICAP
Medicare Advantage Special Needs Plans
Comparison Chart
Company Plan Name
Telephone Numbers Website
Plan Type
Total Monthly Premium Size of Physician and Provider
Network Doctor Visit Specialist Visit Out of Pocket Limit
In-patient Hospitalization
Skilled Nursing Facility
In-patient Mental Health
Outpatient Mental Health Outpatient Hospital Services
Ambulance
Emergency Room Visit Outpatient Rehabilitation
Services
Durable Medical Equipment
Diagnostic Tests
X-Rays Lab Services Renal Dialysis Part B Chemotherapy Drugs
Dental Services
Hearing Services
Vision Services
Transportation
CareMore Health Plan CareMore Health Plan CareMore Health Plan CareMore Health Plan
Breathe ESRD Heart Reliance
New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com
New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com
New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com
New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com SPECIAL NEEDS HMO
(Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic lung disorders.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with end-stage renal disease requiring any mode of dialysis.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with cardiovascular disorders and/or chronic heart failure.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic diabetes mellitus. $0 Monthly Premium $0 Monthly Premium $0 Monthly Premium $0 Monthly Premium 1001-1500 physicians and
providers 1001-1500 physicians and providers 1001-1500 physicians and providers 1001-1500 physicians and providers
$0 each visit $0 each visit $0 each visit $0 each visit
$0 each visit $0 each visit $0 each visit $0 each visit
$3,000 In-Network $3,000 In-Network $3,000 In-Network $3,000 In-Network $0 copay. 250 days each
benefit period. 60 lifetime reserve days
Days 1-5: $75/day, Days 6-90: $0/Day, $0/day after 90 days. 260 days each benefit period.
60 lifetime reserve days.
$0 copay. 250 days each benefit period. 60 lifetime
reserve days.
$0 copay. 270 days each benefit period. 60 lifetime
reserve days. Days 1-31: $0/day, Days
32-100: $25/day. 100 days each benefit period.
Days 1-31: $0/day, Days 32-100: $25/day. 100 days each
benefit period.
Days 1-31: $0/day, Days 32-100: $25/day. 100 days each
benefit period.
Days 1-31: $0/day, Days 32-100: $25/day. 100 days each
benefit period. $0 copay. 150 days each
benefit period.
Days 1-5: $75/day, Days 6-150: $0/Day. 150 days each
benefit period.
$0 copay. 150 days each
benefit period. $0 copay. 150 days each benefit period. $0 each session $0 each session $0 each session $0 each session
$0 each visit $0 each visit $0 each visit $0 each visit
$100 each service. $0-$100 each service, waived if admitted. $100 each service. $100 each service. $65 each visit, waived if
admitted within 24-hrs. $65 each visit, waived if admitted within 24-hrs. $65 each visit, waived if admitted within 24-hrs. $65 each visit, waived if admitted within 24-hrs.
$0 each visit $0 each visit $0 each visit $0 each visit
0-20% for each
Medicare-covered item. 0-20% for each
Medicare-covered item. 0-20% for each
Medicare-covered item. 0-20% for each
Medicare-covered item. $0 for diagnostic
procedures/tests. $0 - $75 for diagnostic radiology services.
$0 for diagnostic procedures/tests. $0 - $75 for
diagnostic radiology services.
$0 for diagnostic procedures/tests. $0 - $75 for
diagnostic radiology services.
$0 for diagnostic procedures/tests. $0 - $75 for
diagnostic radiology services.
$0 each X-ray $0 each X-ray $0 each X-ray $0 each X-ray
$0 each lab service. $60 for
therapeutic radiology services. therapeutic radiology services.$0 each lab service. $60 for therapeutic radiology services.$0 each lab service. $60 for therapeutic radiology services.$0 each lab service. $60 for
$0 copay $0 copay $0 copay $0 copay
20% of the cost 20% of the cost 20% of the cost 20% of the cost $0 for Medicare-covered
benefits. Contact plan for additional benefits.
$0 for Medicare-covered
benefits. Contact plan for additional benefits.
$0 for Medicare-covered
benefits. Contact plan for additional benefits.
$0 for Medicare-covered
benefits. Contact plan for additional benefits. $0 for diagnostic exams.
Contact plan for additional benefits.
$0 for diagnostic exams. Contact plan for additional
benefits.
$0 for diagnostic exams. Contact plan for additional
benefits.
$0 for diagnostic exams. Contact plan for additional
benefits. $0 copay for diagnosis and
treatment of eye conditions. Contact plan for additional
benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
$0 copay $0 copay $0 copay $0 copay
2015 Orange County HICAP
Medicare Advantage Special Needs Plans
Comparison Chart
Company Plan Name
Telephone Numbers Website
Plan Type
Total Monthly Premium Size of Physician and Provider
Network Doctor Visit Specialist Visit Out of Pocket Limit
In-patient Hospitalization
Skilled Nursing Facility
In-patient Mental Health
Outpatient Mental Health Outpatient Hospital Services
Ambulance
Emergency Room Visit Outpatient Rehabilitation
Services
Durable Medical Equipment
Diagnostic Tests
X-Rays Lab Services Renal Dialysis Part B Chemotherapy Drugs
Dental Services
Hearing Services
Vision Services
Transportation Prescription Drugs
CareMore Health Plan Central Health Health Net SCAN
Touch Focus Jade Heart First
New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com
New enrollment: 866-314-2427 Current members: 800-589-3147 centralhealthplan.com
New enrollment: 800-877-4814 Current members: 800-275-9737 healthnet.com/medicare
New enrollment: 877-452-5898 Current members: 800-559-3500 scanhealthplan.com SPECIAL NEEDS HMO
(Institutional) Medicare Health Plan with Prescription Drug Benefit for individuals residing in a long-term care setting.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic diabetes mellitus.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with cardiovascular disorders, chronic heart failure and/or diabetes.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with cardiovascular disorders and/or chronic heart failure.
$0 Monthly Premium $0 Monthly Premium $0 Monthly Premium $0 Monthly Premium
1001-1500 physicians and
providers 4501-5000 physicians and providers 3001-3500 physicians and providers 9001-10000 physicians and providers
$0 each visit $0 each visit $0 each visit $0 each visit
$0 each visit $0 each visit $0 each visit $0 each visit
$3,000 In-Network $3,400 In-Network $3,400 In-Network $3,400 In-Network
$0 copay. 245 days each benefit period. 60 lifetime
reserve days.
$0 copay. Unlimited days each
benefit period. $0 copay. Unlimited days each benefit period. $0 copay. Unlimited days each benefit period.
$0 copay. 100 days each benefit period.
Days 1-20: $0/day, Days 21-65: $75/day. Days 66-100: $0.
100 days each benefit period.
Days 1-31: $0/day, Days 32-100: $25/day. 100 days each
benefit period.
Days 1-20: $0/day, Days 21-100: $25/day. 100 days each
benefit period. $0 copay. 150 days each
benefit period. $0 copay. 190-day psychiatric hospital lifetime limit.
$900 copay. 190-days psychiatric hospital lifetime
limit.
$0 copay. 190-days psychiatric hospital lifetime limit.
$0 each session $5 each session $25 each session $20 each session
$0 each visit $0 each visit $0 - $60 each visit $0-$100 each visit
$100 each service. $50 each service. $40 each service, waived if admitted. $200 each service $65 each visit, waived if
admitted within 24-hrs. $50 each visit, waived if admitted within 24-hrs. $65 each visit, waived if admitted immediately. $65 each visit, waived if immediately admitted. $0 each visit $0 each visit $0 each visit $10 each visit all others$0 each visit cardiac 0-20% for each
Medicare-covered item. 0-20% for each
Medicare-covered item. 10% for each
Medicare-covered item. 0-20% for each Medicare-covered item. $0 for diagnostic
procedures/tests. $0 - $75 for diagnostic radiology services.
$0 for diagnostic procedures/tests. $0 for diagnostic radiology services.
$0 for diagnostic procedures/tests. $60 for diagnostic radiology services.
$0 for diagnostic procedures/tests. $100 for diagnostic radiology services.
$0 each X-ray $0 each X-ray $0 each X-ray $0 each X-ray
$0 each lab service. $60 for therapeutic radiology services.
$0 each lab service. 20% of the cost for therapeutic radiology
services.
$0 each lab service. $60 for
therapeutic radiology services. therapeutic radiology services.$0 each lab service. $50 for
$0 copay 20% of the cost 20% of the cost $0 copay
20% of the cost 20% of the cost 20% of the cost 20% of the cost
$0 for Medicare-covered benefits. Preventive benefits
not covered.
$0 for Medicare-covered benefits. Contact plan for
additional benefits.
$0 for Medicare-covered benefits. Contact plan for
additional benefits.
$0 for Medicare-covered benefits. Preventive benefits
not covered. $0 for diagnostic exams.
Contact plan for additional benefits.
$0 for diagnostic exams. Contact plan for additional
benefits.
$0 for diagnostic exams. Contact plan for additional
benefits.
$0 for diagnostic exams. Contact plan for additional
benefits. $0 copay for diagnosis and
treatment of eye conditions. Contact plan for additional
benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
$0 copay $0 copay $0 copay $0 copay
See separate Chart See separate Chart See separate Chart See separate Chart
2015 Orange County HICAP
Medicare Advantage Special Needs Plans
Comparison Chart
Company Plan Name
Telephone Numbers Website
Plan Type
Total Monthly Premium Size of Physician and Provider
Network Doctor Visit Specialist Visit Out of Pocket Limit
In-patient Hospitalization
Skilled Nursing Facility
In-patient Mental Health
Outpatient Mental Health Outpatient Hospital Services
Ambulance
Emergency Room Visit Outpatient Rehabilitation
Services
Durable Medical Equipment
Diagnostic Tests
X-Rays Lab Services Renal Dialysis Part B Chemotherapy Drugs
Dental Services
Hearing Services
Vision Services
Transportation
SCAN SCAN VillageHealth
Balance Healthy at Home VillageHealth
New enrollment: 877-452-5898 Current members: 800-559-3500 scanhealthplan.com
New enrollment: 877-452-5898 Current members: 800-559-3500 scanhealthplan.com
New enrollment: 877-916-1234 Current members: 800-399-7226 villagehealthca.com SPECIAL NEEDS HMO
(Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with diabetes mellitus.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those qualify for nursing home care but are deemed eligible to live in their own home.
SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with end-stage renal disease requiring any mode of dialysis . $0 Monthly Premium $0 Monthly Premium Contact Plan for health plan $28.80 Monthly Premium
deductible 9001-10000 physicians and
providers 15001-16000 physicians and providers 3001-3500 physicians and providers
$0 each visit $10 each visit $0 each visit
$0 each visit $20 each visit 20% of the cost each visit $3,400 In-Network $6,700 In-Network $6,700 In-Network $0 copay. Unlimited days each
benefit period.
Days 1-10: $150/day. Days 11-90: $0, $0/day after 90 days.
Unlimited days each benefit period.
90 days each benefit period. 60 lifetime reserve days. Contact plan for more details. Days 1-20: $0/day, Days
21-100: $25/day. 100 days each benefit period.
Days 1-20: $0/day, Days 21-100: $100/day. 100 days each
benefit period.
100 days each benefit period. Contact plan for more details.
$0 copay. 190-days psychiatric hospital lifetime limit.
Days 1-10: $150/day. Days 11-90: $0. Contact plan for days
beyond 90. 190-days psychiatric hospital lifetime
limit.
190-day psychiatric hospital lifetime limit. Contact plan for
more details. $20 each session $35 each session 20% of the cost each session $0-$100 each visit $20-$100 or 20% of the cost each visit 20% of the cost each visit $200 each service $110 each service 20% of the cost each service $65 each visit, waived if
immediately admitted. $65 each visit, waived if immediately admitted. $65 each visit $0 each visit cardiac
$10 each visit all others $20 each visit 20% of the cost each visit 0-20% for each
Medicare-covered item.
20% for each Medicare-covered item.
20% for each Medicare-covered item. $0 for diagnostic
procedures/tests. $100 for diagnostic radiology services.
$0 for diagnostic procedures/tests. 20% of the costs for diagnostic radiology
services.
20% of the cost for diagnostic procedures/tests. 20% of the cost for diagnostic radiology
services. $0 each X-ray $0 each X-ray 20% of the cost each X-ray $0 each lab service. $50 for
therapeutic radiology services.
$0 each lab service. 20% of the costs for therapeutic radiology
services.
$0 each lab service. 20% of the cost for therapeutic radiology
services.
$0 copay $0 copay 20% of the cost
20% of the cost 20% of the cost 0% -20% of the cost $0 for Medicare-covered
benefits. Preventive benefits not covered.
$20 for Medicare-covered benefits. Preventive benefits
not covered.
20% of the cost for Medicare-covered benefits. Contact plan
for additional benefits. $0 for diagnostic exams.
Contact plan for additional benefits.
$20 for diagnostic exams. Routine exams and hearing
aids not covered.
20% of the cost for diagnostic exams. Routine exams and
hearing aids not covered. $0 copay for diagnosis and
treatment of eye conditions. Contact plan for additional
benefits.
$0 copay for diagnosis and treatment of eye conditions.
Contact plan for additional benefits.
0-20% of the cost for diagnosis and treatment of eye conditions. Contact plan for
additional benefits. $0 copay Transportation not covered. $0 copay