Page 17 - ITDR Benefits & Resources guide 2019

MEDICAL PLAN
SUPPLEMENT-TYPE PLAN
MEDICARE ADVANTAGE STANDARD PLAN
MEDICARE ADVANTAGE ENHANCED PLAN
PHYSICAL THERAPY
For Medicare-covered physical therapy. Deductible applies to all services with coinsurance or copays under the Supplement-Type Plan and Medicare Advantage Standard Plan.
For the Medicare Advantage Standard Plan and the Medicare Advantage Enhanced Plan, your provider must obtain approval from the plan before you get physical therapy, occupational therapy, and speech language therapy visits. This is called getting prior authorization.
10% coinsurance.
$40 copay for physical therapy, occupational therapy, and speech language
therapy visits.
$25 copay for physical therapy, occupational therapy, and speech language
therapy visits.
AMBULANCE
For Medicare-covered ambulance services. Deductible applies to all services with coinsurance under the Supplement-Type Plan.
For the Medicare Advantage Standard Plan and the Medicare Advantage Enhanced Plan, your provider must obtain approval from the plan before you get ground, air, or water transportation that is not an emergency. This is called getting prior authorization. Claims received without approval are subject to review and may include a medical necessity evaluation.
10% coinsurance.
10% coinsurance per one-way trip.
HOSPICE CARE
Member pays $0.
$40 copay for the one time only hospice consultation. Deductible does not apply.
$25 copay for the one time only hospice consultation.
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Medical Plan