Page 41 - MAPD_HMO_FLIP

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

Vision Services
Medicare-Covered Eye $40 copay $35 copay In-network:
Exam: $35 copay
Out-of-Network:
$65 copay
Eyewear after cataract $0 copay $0 copay In and Out-of-Network:
surgery: (for Medicare- $0 copay
covered standard
eyewear)
Routine eye exam:** $40 copay $35 copay In-network: $35 copay.
(up to 1 per year) Out-of-Network:
Not covered
Eyewear:** (For covered Our plan pays up to Our plan pays up to In-network: Our plan
eyewear, you pay any $150 every two years $150 every two years pays up to $150 every
balance in excess of the for eyewear for eyewear two years for eyewear
$150 limit.) Out-of-network:
Not covered
Mental Health
Services
Inpatient Visit: • $275 copay per day • $150 copay per day for In-network:
for days 1 through 5 days 1 through 5 • $200 copay per day for
• You pay nothing • You pay nothing days 1 through 5
per day for days 6 per day for days 6 • You pay nothing
through 90 through 90 per day for days 6
• You pay nothing per • You pay nothing per through 90
day for days 91 and day for days 91 and • You pay nothing per
beyond beyond day for days 91 and
beyond
Out-of-network:
• 20% of the cost per stay
Outpatient group $40 copay $35 copay In-network: $35 copay
therapy visit: Out-of-network:
20% of the cost

Outpatient individual $40 copay $35 copay In-network: $35 copay
therapy visit: Out-of-network:
20% of the cost
Authorization rules Authorization rules Authorization rules
may apply. may apply. may apply.

**You must use Davis Vision network providers for routine vision care and eyewear.

9

5901 163138M-3_HMO Summary.indd 11 11/11/16 4:23 PM