Page 13 - 2022 Smart Solutions - MR

Service category
Monthly plan premium
Maximum Out-of-Pocket
Primary Care Physician (PCP) Visits
Specialist Visits
Inpatient Hospital
(including COVID-19 coverage)
Routine Podiatry‡ Routine Chiropractic‡ Routine Acupuncture§
Over-the-Counter (OTC) Items (InComm)
Telemedicine Visits (MDLIVE)
Outpatient Diagnostic Radiology Services Dental/Vision/Hearing
Prescription drugs
Preferred Retail and Mail Order (90-day supply for 2 months' copay)
Preferred Retail Cost-Sharing (30-day supply)
Standard Retail Cost-Sharing (30-day supply)
Initial Coverage Limit
Coverage Gap Catastrophic
Personal Choice 65 PPO
Philadelphia and Bucks
Medical-only $179
Chester, Delaware, Montgomery
N/A
Medical with Rx $294
$165
$5,000 in-network; $10,000 combined in- and out-of-network $0 copay
$35 copay
$240 copay per day for days 1 – 6; no copay for additional days
per admission; $1,440 maximum per admission; $0 copay for in-network inpatient hospital stay — acute due to COVID-19 diagnosis
$20 copay per visit (up to 6 visits per year) $20 copay per visit (up to 6 visits per year) $20 copay per visit (up to 6 visits per year)
$30 quarterly allowance1
$0 copay for medical doctor visits focused on non-urgent
medical conditions; NEW! $0 copay for behavioral health visits focused on therapy and counseling services
$0 copay for certain diagnostic tests;
$40 or $175 copay depending on the service
Included in plan! See page <14> for details.
Preferred Generic, $0 copay; Generic, $18 copay
Preferred Generic, $0 copay; Generic, $9 copay; Preferred Brand, $47 copay; Non-Preferred Drug, $100 copay; Specialty Drug, 33% coinsurance
Preferred Generic, $9 copay; Generic, $20 copay; Preferred Brand, $47 copay; Non-Preferred Drug, $100 copay; Specialty Drug,
33% coinsurance
A maximum of $4,430 in total drug cost
You pay 25% of generic drug costs and 25% of brand-name drug costs until you reach a maximum of $7,050
You pay the greater of $3.95 for generics and $9.85 for brand-name drugs or 5% coinsurance after reaching a maximum of $7,050 catastrophic trigger
1Quarterly OTC allowance does not carry over.
‡Routine Podiatry, Chiropractic, and Acupuncture visits are in addition to Medicare-covered services.
§Must have one of the following conditions: headache (migraine and tension), post-operative nausea and vomiting,
chemotherapy-induced nausea and vomiting,low back pain, chronic neck pain, or pain from osteoarthritis of the knee and hip.
13