GoldAnywhere with Part D - Option 2 (PPO) Benefits

MVP HEALTH CARE | PPO
Plan website: www.joinMVPmedicare.com
Plan Phone Number: (888) 280-6205
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.

$2 250 out-of-pocket limit every year.

$750 copay for each Medicare-covered hospital stay

$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.

40% of the cost for each Medicare-covered hospital stay.

Outpatient Care

Doctor Office Visits

Authorization rules may apply.

$25 copay for each Medicare-covered primary care doctor visit.

$50 copay for each Medicare-covered specialist visit.

$60 copay for each Medicare-covered primary care doctor visit

$60 copay 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 copay for Medicare-covered:

diagnostic procedures and tests

$10 copay for Medicare-covered lab services

$50 copay for Medicare-covered X-rays

$60 copay for Medicare-covered diagnostic radiology services (not including X-rays)

$0 copay for Medicare-covered therapeutic radiology services

40% of the cost for Medicare-covered therapeutic radiology services

$60 copay for Medicare-covered outpatient X-rays

40% of the cost for Medicare-covered diagnostic radiology services

40% of the cost for Medicare-covered diagnostic procedures and tests

40% of the cost for Medicare-covered lab services

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

You may pay less if you purchase these items from the plan's preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors.

40% of the cost for Medicare-covered durable medical equipment

Diabetes Programs and Supplies

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

10% of the cost for Medicare-covered Diabetes monitoring supplies

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

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

40% of the cost for Medicare-covered Diabetes monitoring supplies

40% of the cost for Medicare-covered Therapeutic shoes or inserts

Ambulance Services

Authorization rules may apply.

$125 copay for Medicare-covered ambulance benefits.

$125 copay for Medicare-covered ambulance benefits.

Urgently Needed Care

$50 copay for Medicare-covered urgently-needed-care visits

Outpatient Services

Authorization rules may apply.

$250 copay for each Medicare-covered ambulatory surgical center visit

$500 copay for each Medicare-covered outpatient hospital facility visit

40% of the cost for Medicare-covered outpatient hospital facility visits

40% of the cost for Medicare-covered ambulatory surgical center visits

Chiropractic Services

Authorization rules may apply.

$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).

$20 copay 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

$50 copay for Medicare-covered partial hospitalization program services

$60 copay for Medicare-covered Mental Health visits with a psychiatrist

$60 copay for Medicare-covered Mental Health visits

$60 copay for Medicare-covered partial hospitalization program services

Podiatry Services

Authorization rules may apply.

$50 copay for each Medicare-covered podiatry visit

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

$60 copay for Medicare-covered podiatry visits

Substance Abuse Care

Authorization rules may apply.

$50 copay for Medicare-covered individual substance abuse outpatient treatment visits

$50 copay for Medicare-covered group substance abuse outpatient treatment visits

$60 copay 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.

$50 copay for Medicare-covered Occupational Therapy visits

$50 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits

$60 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits

$60 copay for Medicare-covered Occupational Therapy visits.

Prosthetic Devices

Authorization rules may apply.

20% of the cost for Medicare-covered prosthetic devices

0% of the cost for Medicare-covered medical supplies related to prosthetics splints and other devices

40% 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 Medicare-covered preventive services

Cardiac and Pulmonary Rehabilitation Services

Authorization rules may apply.

$50 copay for Medicare-covered Cardiac Rehabilitation Services

$50 copay for Medicare-covered Intensive Cardiac Rehabilitation Services

$50 copay for Medicare-covered Pulmonary Rehabilitation Services

$60 copay for Medicare-covered Cardiac Rehabilitation Services

$60 copay for Medicare-covered Intensive Cardiac Rehabilitation Services

$60 copay for Medicare-covered Pulmonary Rehabilitation Services

Kidney Disease and Conditions

Authorization rules may apply.

$0 copay for Medicare-covered renal dialysis

$0 copay for Medicare-covered kidney disease education services

$0 copay for Medicare-covered kidney disease education services

$0 copay for Medicare-covered renal dialysis

Additional Benefits

Dental Services

In general preventive dental benefits (such as cleaning) not covered.

$50 copay for Medicare-covered dental benefits

$60 copay for Medicare-covered comprehensive dental benefits

Hearing Services

Hearing aids not covered.

$50 copay for Medicare-covered diagnostic hearing exams

$50 copay for up to 1 supplemental routine hearing exam(s) every year

$60 copay for Medicare-covered diagnostic hearing exams.

$60 copay for supplemental hearing exams.

Vision Services

$50 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye including an annual glaucoma screening for people at risk

$50 copay for up to 1 supplemental routine eye exam(s) every year

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

$60 copay for Medicare-covered eye exams

$60 copay for supplemental routine eye exams

40% of the cost for Medicare-covered eyewear

Over-the-Counter Items

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

Mental Health Care

You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

The out-of-pocket limit is covered under "Inpatient Hospital Care."

$750 copay for each Medicare-covered hospital stay.

Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.

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

40% of the cost for each Medicare-covered hospital stay.

Skilled Nursing Facility (SNF)

Authorization rules may apply.

Plan covers up to 100 days each benefit period

3-day prior hospital stay is required.

For Medicare-covered SNF stays:

Days 1 - 20: $25 copay per day

Days 21 - 100: $150 copay per day

40% of the cost for each Medicare-covered SNF stay.

Home Health Care

Authorization rules may apply.

$0 copay for Medicare-covered home health visits

40% 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

50% of the cost per visit up to 10 visit(s) for acupuncture and other alternative therapies every year

50% of the cost for visits for acupuncture and other alternative therapies

Wellness/Education & Other Benefits

The plan covers the following supplemental education/wellness programs:

Health Education

Nutritional Benefit

Additional Smoking and Tobacco Use Cessation Visits

Health Club Membership/Fitness Classes

Nursing Hotline

Enhanced Disease Management

$0 copay for supplemental education/wellness programs

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