Page 42 - MAPD_HMO_FLIP

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

Skilled Our plan covers up to Our plan covers up to Our plan covers up to
Nursing Facility 100 days in a SNF. 100 days in a SNF. 100 days in a SNF.
(SNF) • You pay nothing • $20 copay per day for In-network:
per day for days 1 days 1 through 20 • You pay nothing
through 20 • $100 copay per day for per day for days 1
• $160 copay per day for days 21 through 44 through 20
days 21 through 44 • You pay nothing • $140 copay per day
• You pay nothing per day for days 45 for days 21 through 44
per day for days 45 through 100 • You pay nothing per
through 100 Authorization rules day for days 45
Authorization rules may apply. through 100
may apply. Out-of-network:
• 20% of the cost per stay
Authorization rules
may apply.
Rehabilitation
Services
Occupational $20 copay $15 copay In-network: $15 copay
therapy visit: Out-of-network:
20% of the cost
Physical therapy and $20 copay $15 copay In-network: $15 copay
speech and language Out-of-network:
therapy visit: 20% of the cost
Authorization rules Authorization rules Authorization rules
may apply. may apply. may apply.
Referral from your Referral from your Referral from your
doctor may be required. doctor may be required. doctor may be required.
Ambulance $100 copay $100 copay In-network: $100 copay
If you are admitted to If you are admitted to Out-of-network:
the hospital, you do the hospital, you do $100 copay
not have to pay for the not have to pay for the If you are admitted to
ambulance services. ambulance services. the hospital, you do
Authorization rules may Authorization rules may not have to pay for the
apply. apply. ambulance services.
Authorization rules
may apply.
Transportation Not covered Not covered Not covered

10

5901 163138M-3_HMO Summary.indd 12 11/11/16 4:23 PM