Medical Benefits
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MDwise Medicare Inspire (HMO)
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MDwise Medicare Inspire Plus (HMO)
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MDwise Medicare Inspire Flex (HMO-POS)
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Inpatient Hospital Coverage
We cover an unlimited number of days for an inpatient hospital stay.
Prior authorization may be
required.
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$295 copay per day for days 1 through 7
You pay nothing per day for days 8 through 90
You pay nothing per day for days 91 and beyond
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$290 copay per day for days 1 through 7
You pay nothing per day for days 8 through 90
You pay nothing per day for days 91 and beyond
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In-network
$310 copay per day for days 1 through 7
You pay nothing per day for days 8 through 90
You pay nothing per day for days 91 and beyond
Point-of-service
30% of the cost/stay
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Outpatient Hospital Coverage
Prior authorization and referral may be required.
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Outpatient Hospital:
$275 copay for each visit
Ambulatory Surgical Center: $250 copay for each visit
Observation:
$275 copay for each visit
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Outpatient Hospital:
$275 copay for each visit
Ambulatory Surgical Center: $250 copay for each visit
Observation:
$275 copay for each visit
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In-network Outpatient Hospital:
$275 copay for each visit
Ambulatory Surgical Center: $250 copay for each visit
Observation:
$275 copay for each visit
Point-of-service
30% of the cost
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Doctor Visits
Specialist visits require a
referral.
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Primary Care:
$5 copay per visit
Specialist:
You pay a $40 copay per visit
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Primary Care:
$0 copay per visit
Specialist:
You pay a $40 copay per visit
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In-network Primary Care:
$0 copay per visit
Specialist:
You pay a $40 copay per visit
Point-of-service
30% of the cost
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Preventive Care
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You pay nothing
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You pay nothing
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In-network
You pay nothing
Point-of-service
30% of the cost
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Emergency Care
Your copay will be waived if you are admitted directly into the hospital.
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You pay a $90 copay per visit in or out of network
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You pay a $90 copay per visit in or out of network
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You pay a $90 copay per visit in or out of network
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Urgently Needed Services
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You pay a $40 copay per visit in or out
of network
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You pay a $40 copay per visit in or out
of network
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You pay a $40 copay per visit in or out of
network
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Outpatient Diagnostic Services/Labs/ Imaging
Prior authorization and referral may be required. Outpatient X-rays do not require prior authorization or referral.
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Diagnostic radiology service (CT/MRI):
$200 copay
Lab services: $0 copay
Diagnostic tests and procedures:
$50 copay
Outpatient X-rays:
$25 copay
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Diagnostic radiology service (CT/MRI):
$150 copay
Lab services: $0 copay
Diagnostic tests and procedures:
$30 copay
Outpatient X-rays:
$25 copay
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In-network Diagnostic radiology service (CT/MRI):
$150 copay
Lab services: $0 copay
Diagnostic tests and procedures:
$30 copay
Outpatient X-rays:
$25 copay
Point-of-service
30% of the cost
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Hearing Services
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Hearing exams: You pay a $40 copay for a Medicare-covered
hearing exam
You pay a $10 copay for non-Medicare covered routine hearing exams
Hearing aids: You pay a $10 for one hearing aid fitting and evaluation per year.
You will be reimbursed for up to $750 per year for hearing aids.
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Hearing exams: You pay a $30 copay for a Medicare-covered
hearing exam
You pay a $0 copay for non-Medicare covered routine hearing exams
Hearing aids: You pay a $0 for one hearing aid fitting and evaluation per year.
You will be reimbursed for up to $1500 per year for hearing aids.
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In-network Hearing exams:
You pay a $30 copay for a Medicare-covered hearing exam
You pay a $0 copay for non-Medicare covered routine hearing exams
Point-of-service
30% of the cost
Hearing aids: You pay a $0 for one hearing aid fitting and evaluation per year.
You will be reimbursed for up to $1500 per year for hearing aids.
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Dental Services
In-network preventive dental services are provided by Delta Dental’s Medicare Advantage PPO and Premier network dentists.
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Oral exam and cleaning: $0 copay for two exams and two cleanings each year
Filings and crown repair: 50% coinsurance
Fluoride treatment: $0 copay for one treatment each year
Bitewing X-rays: $0 copay for one set each year
Full mouth X-rays: $0 copay once every 5 years
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Vision Services
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Medicare-covered services:
$40 copay for each visit
$0 copay for eyeglasses or contact lenses after cataract surgery
$0 copay for glaucoma screening
Routine vision services:
$0 copay for a routine eye exam
$0 copay for non- Medicare-covered routine corrective eyeglasses (lenses and frames) or contact lenses.
You will be reimbursed up to a maximum of
$100 each year.
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Medicare-covered services:
$30 copay for each visit
$0 copay for eyeglasses or contact lenses after cataract surgery
$0 copay for glaucoma screening
Routine vision services:
$0 copay for a routine eye exam
$0 copay for non- Medicare-covered routine corrective eyeglasses (lenses and frames) or contact lenses.
You will be reimbursed up to a maximum of
$200 each year.
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In-network Medicare-covered services:
$30 copay for each visit
$0 copay for eyeglasses or contact lenses after cataract surgery
$0 copay for glaucoma screening
Point-of-service
30% of the cost
Routine vision services:
$0 copay for a routine eye exam
$0 copay for non- Medicare-covered routine corrective eyeglasses (lenses and frames) or contact lenses.
You will be reimbursed up to a maximum of
$200 each year.
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Mental Health Services
Our plan covers up to 190 days in a lifetime for inpatient care in a psychiatric hospital. Our
plan covers 90 days for an
inpatient hospital stay.
Prior authorization may be required for inpatient mental health services.
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Inpatient:
$265 copay per day for days 1 through 7
You pay nothing per day for days 8 through 90
Outpatient therapy (group or individual):
$30 copay per session
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Inpatient:
$265 copay per day for days 1 through 7
You pay nothing per day for days 8 through 90
Outpatient therapy (group or individual):
$25 copay per session
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In-network Inpatient:
$265 copay per day for days 1 through 7
You pay nothing per day for days 8 through 90
Outpatient therapy (group or individual):
$25 copay per session
Point-of-service
30% of the cost
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Skilled Nursing Facility (SNF)
Our plan covers up to 100 days each benefit period in a SNF. A benefit period starts the day you go into a SNF and ends when
you go 60 days in a row
without SNF care.
Prior authorization may be
required.
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You pay nothing per day for days 1 through 20
$188 copay per day for days 21 through 100
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You pay nothing per day for days 1 through 20
$188 copay per day for days 21 through 100
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In-network
You pay nothing per day for days 1 through 20
$188 copay per day for days 21 through 100
Point-of-service
30% of the cost
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Physical Therapy
Prior authorization and
referral may be required.
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$40 copay per visit
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$40 copay per visit
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In-network
$40 copay per visit
Point-of-service
30% of the cost
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Ambulance
Prior authorization may be required for Medicare covered non-emergency transport.
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$250 copay per one-way transport
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$250 copay per one-way transport
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$250 copay per one-way transport in or
out of network
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Transportation
Prior authorization and
referral may be required.
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Not covered
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Not Covered
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Not covered
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Medicare Part B Drugs
Prior authorization may be required
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Chemotherapy and Other Part B Drugs: 20% of the cost
Home Infusion Drugs:
$0 copay
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Chemotherapy and Other Part B Drugs: 20% of the cost
Home Infusion Drugs:
$0 copay
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In-network Chemotherapy and Other Part B Drugs: 20% of the cost
Home Infusion Drugs: $0 copay
Point-of-service
30% of the cost
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