Coventry Advantra Platinum (PPO) Benefits

Coventry Health Care | PPO
Plan website: iowa-nebraska.chcadvantra.com
Plan Phone Number: (855) 893-1444
U.S. News Preferred Broker Phone: (888) 245-3931

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Inpatient Care

Hospital Care

No limit to the number of days covered by the plan each hospital stay.

For Medicare-covered hospital stays:

Days 1 - 5: $390 copay per day

Days 6 - 90: $0 copay per day

$0 copay for additional non-Medicare-covered hospital days

Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.

For Medicare-covered hospital stays:

Days 1 and beyond: 30% of the cost per day

Outpatient Care

Doctor Office Visits

$5 copay for each Medicare-covered primary care doctor visit.

$40 copay for each Medicare-covered specialist visit.

30% of the cost for each Medicare-covered primary care doctor visit

30% of the cost for each Medicare-covered specialist visit

Doctor and Hospital Choice

No referral required for network doctors specialists and hospitals.

You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits.

Diagnostic Tests, X-Rays, Lab Services and Radiology Services

Authorization rules may apply.

0% of the cost for Medicare-covered lab services

0% to 20% of the cost for Medicare-covered diagnostic procedures and tests

20% of the cost for Medicare-covered X-rays

$250 copay for Medicare-covered diagnostic radiology services (not including X-rays)

20% of the cost for Medicare-covered therapeutic radiology services

If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $0 to $40 may apply

If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $0 to $40 may apply

30% of the cost for Medicare-covered therapeutic radiology services

30% of the cost for Medicare-covered outpatient X-rays

30% of the cost for Medicare-covered diagnostic radiology services

30% of the cost for Medicare-covered diagnostic procedures and tests

30% of the cost for Medicare-covered lab services

If the doctor provides you services in addition to (Medicarecovered Diagnostic Procedures/Tests Medicarecovered Laboratory Services Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays ) separate cost sharing of 0% to 30% of the cost may apply

Emergency Care

$65 copay for Medicare-covered emergency room visits

Worldwide coverage.

If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit.

Durable Medical Equipment

Authorization rules may apply.

20% of the cost for Medicare-covered durable medical equipment

30% of the cost for Medicare-covered durable medical equipment

Diabetes Programs and Supplies

Authorization rules may apply.

$0 copay for Medicare-covered Diabetes self-management training

0% to 20% of the cost for Medicare-covered Diabetes monitoring supplies

20% of the cost for Medicare-covered Therapeutic shoes or inserts

Diabetic Supplies and Services are limited to specific manufacturers products and/or brands. Contact the plan for a list of covered supplies.

If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $0 to $40 may apply

0% of the cost for Medicare-covered Diabetes self-management training

0% to 30% of the cost for Medicare-covered Diabetes monitoring supplies

0% to 30% of the cost for Medicare-covered Therapeutic shoes or inserts

If the doctor provides you services in addition to (Diabetes Self-Management Training ) separate cost sharing of 0% to 30% of the cost may apply

Ambulance Services

$250 copay for Medicare-covered ambulance benefits.

$250 copay for Medicare-covered ambulance benefits.

Urgently Needed Care

$40 copay for Medicare-covered urgently-needed-care visits

If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the urgently-needed-care visit.

Outpatient Services

Authorization rules may apply.

20% of the cost for each Medicare-covered ambulatory surgical center visit

20% of the cost for each Medicare-covered outpatient hospital facility visit

30% of the cost for Medicare-covered outpatient hospital facility visits

30% of the cost for Medicare-covered ambulatory surgical center visits

Chiropractic Services

$20 copay for each Medicare-covered chiropractic visit

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).

30% of the cost for Medicare-covered chiropractic visits.

Outpatient Mental Health Care

Authorization rules may apply.

$40 copay for each Medicare-covered individual therapy visit

$40 copay for each Medicare-covered group therapy visit

$40 copay for each Medicare-covered individual therapy visit with a psychiatrist

$40 copay for each Medicare-covered group therapy visit with a psychiatrist

20% of the cost for Medicare-covered partial hospitalization program services

30% of the cost for Medicare-covered Mental Health visits with a psychiatrist

30% of the cost for Medicare-covered Mental Health visits

30% of the cost for Medicare-covered partial hospitalization program services

Podiatry Services

$40 copay for each Medicare-covered podiatry visit

Medicare-covered podiatry visits are for medically necessary foot care.

30% of the cost for Medicare-covered podiatry visits

Substance Abuse Care

Authorization rules may apply.

$40 copay for Medicare-covered individual substance abuse outpatient treatment visits

$40 copay for Medicare-covered group substance abuse outpatient treatment visits

30% of the cost for Medicare-covered substance abuse outpatient treatment visits

Outpatient Rehabilitation Services

Authorization rules may apply.

Medically necessary physical therapy occupational therapy and speech and language pathology services are covered.

$40 copay for Medicare-covered Occupational Therapy visits

$40 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits

30% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits

30% of the cost for Medicare-covered Occupational Therapy visits.

Prosthetic Devices

Authorization rules may apply.

20% of the cost for Medicare-covered prosthetic devices

20% of the cost for Medicare-covered medical supplies related to prosthetics splints and other devices

30% of the cost for Medicare-covered prosthetic devices.

Preventive Services

$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.

$0 copay for a supplemental annual physical exam

0% of the cost for Medicare-covered preventive services

0% of the cost for a supplemental annual physical exam

Cardiac and Pulmonary Rehabilitation Services

Authorization rules may apply.

$0 copay for:

Medicare-covered Cardiac Rehabilitation Services

Medicare-covered Intensive Cardiac Rehabilitation Services

Medicare-covered Pulmonary Rehabilitation Services

30% of the cost for Medicare-covered Cardiac Rehabilitation Services

30% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services

30% of the cost for Medicare-covered Pulmonary Rehabilitation Services

Kidney Disease and Conditions

20% of the cost for Medicare-covered renal dialysis

$0 copay for Medicare-covered kidney disease education services

0% of the cost for Medicare-covered kidney disease education services

30% of the cost for Medicare-covered renal dialysis

Additional Benefits

Dental Services

$0 copay for the following preventive dental benefits:

up to 1 oral exam(s) every year

up to 1 cleaning(s) every year

up to 1 dental x-ray(s) every year

20% of the cost for Medicare-covered dental benefits

30% of the cost for Medicare-covered comprehensive dental benefits

30% of the cost for supplemental preventive dental benefits

The plan will pay up to $500 for all of the following services combined: Supplemental Preventive Dental

$500 plan coverage limit for supplemental preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits.

Hearing Services

In general supplemental routine hearing exams and hearing aids not covered.

20% of the cost for Medicare-covered diagnostic hearing exams

30% of the cost for Medicare-covered diagnostic hearing exams.

Vision Services

This plan offers only Medicare-covered eye care and eyewear

0% to 20% of the cost for Medicare-covered exams to diagnose and treat diseases and conditions of the eye including an annual glaucoma screening for people at risk

20% of the cost for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery.

If the doctor provides you services in addition to eye exams separate cost sharing of $0 to $40 may apply

0% to 30% of the cost for Medicare-covered eye exams

30% of the cost for Medicare-covered eyewear

If the doctor provides you services in addition to (Eye Exams ) separate cost sharing of 0% to 30% of the cost may apply

Over-the-Counter Items

The plan does not cover Over-the-Counter items.

Mental Health Care

Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days.

For Medicare-covered hospital stays:

Days 1 - 7: $200 copay per day

Days 8 - 90: $0 copay per day

$0 copay for additional non-Medicare-covered hospital days

Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.

For Medicare-covered hospital stays:

Days 1 and beyond: 30% of the cost per day

Skilled Nursing Facility (SNF)

Authorization rules may apply.

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

For Medicare-covered SNF stays:

Days 1 - 20: $50 copay per day

Days 21 - 100: $150 copay per day

For each Medicare-covered SNF stay:

Days 1 - 100: 30% of the cost per SNF day

Home Health Care

Authorization rules may apply.

$0 copay for Medicare-covered home health visits

30% of the cost for Medicare-covered home health visits

Hospice

You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.

Transportation

This plan does not cover supplemental routine transportation.

Acupuncture

This plan does not cover Acupuncture and other alternative therapies.

Wellness/Education & Other Benefits

The plan covers the following supplemental education/wellness programs:

Health Education

Nutritional Benefit

Health Club Membership/Fitness Classes

$0 to $50 copay for supplemental education/wellness programs

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