| Benefits* | Description | In-Network Costs |
|---|---|---|
Doctor visits |
No copays for visits to your primary care provider (PCP), and low copays for endocrinologists, and cardiologists | $0 co-pay for PCPs, $10 co-pay for endocrinologists and cardiologists |
Immunizations |
Pneumonia vaccine
Influenza vaccine COVID-19 vaccine Hepatitis B vaccine |
$0 – there is no coinsurance, copayment or deductible for the pneumonia, influenza, COVID-19, and hepatitis B vaccines |
Preventive
|
Many preventive services are covered, including annual wellness visit, breast cancer screening, colorectal cancer screening, diabetes screening | $0 cost to member |
Help with diabetes insulin and supplies |
Reduced cost sharing across a number of services, including reduced copays for all forms of insulin, diabetes supplies and services, and diabetic shoes |
$35 co-pay for a one month supply of all forms of insulin
offered by participating drug
manufacturers
$0 co-pay for diabetic supplies and services 20% coinsurance for diabetic shoes and inserts Prior authorization is required |
Dental services |
Preventive and comprehensive dental services include oral exams, dentures, x-rays, extractions, fillings and deep cleanings |
$0 cost to member
The benefit is $1,250 annually |
Routine vision services with eyewear |
Routine vision screening, lenses, frames, and/or contacts |
$0 cost to member
The benefit is $250 annually |
Home-delivered meals |
One-time benefit of 3 meals per day for 7 days after discharge from the hospital |
$0 cost to member
This benefit requires case manager approval |
Hearing services |
Routine hearing exams, hearing aids, and hearing aid services (including evaluation and fitting, repair, and batteries) |
$0 cost to member
The benefit is $1,500 annually |
No copays for visits to your primary care provider (PCP), and low copays for endocrinologists, and cardiologists
$0 co-pay for PCPs, $10 co-pay for endocrinologists and cardiologists
Pneumonia vaccine
Influenza vaccine
COVID-19 vaccine
Hepatitis B vaccine
$0 – there is no coinsurance, copayment or deductible for the pneumonia, influenza, COVID-19, and hepatitis B vaccines
Many preventive services are covered, including annual wellness visit, breast cancer screening, colorectal cancer screening, diabetes screening
$0 cost to member
Reduced cost sharing across a number of services, including reduced copays for all forms of insulin, diabetes supplies and services, and diabetic shoes
$35 co-pay for a one month supply of all forms of insulin
offered by participating drug
manufacturers
$0 co-pay for diabetic supplies and services
20% coinsurance for diabetic shoes and inserts
Prior authorization is required
Preventive and comprehensive dental services include oral exams, dentures, x-rays, extractions, fillings and deep cleanings
$0 cost to member
The benefit is $1,250 annually
Routine vision screening, lenses, frames, and/or contacts
$0 cost to member
The benefit is $250 annually
One-time benefit of 3 meals per day for 7 days after discharge from the hospital
$0 cost to member
This benefit requires case manager approval
Routine hearing exams, hearing aids, and hearing aid services (including evaluation and fitting, repair, and batteries)
$0 cost to member
The benefit is $1,500 annually
| Benefits* | Description | In-Network Costs |
|---|---|---|
Skilled nursing facility (SNF) |
No prior hospital stay is required |
$0 cost to member days
1 through 100 |
Immunizations |
Vaccines for COVID-19, pneumonia, influenza, and Hepatitis B | $0 cost to member |
Preventive services |
Many preventive services are covered, including an annual wellness visit, breast cancer screening, colorectal cancer screening, diabetes screening | $0 cost to member |
Dental services |
Preventive and comprehensive dental services include oral exams, dentures, x-rays, extractions, fillings, and deep cleanings |
$0 cost for up to $2,200
benefit for Ohio members,
$2,350 for Maryland members, $1,750 for Indiana members |
Vision services |
Routine vision screening, lenses, frames, and/or contacts | $0 cost to member for up to $250 per year |
Comfort care items |
Members may select from a catalog of products such as shampoo, lotion, deodorant, lip balm, socks, and more | $0 cost to member for up to $100 per month (OH & MD members) and $94 (IN members) (the unused amount does not roll over) |
Hearing services |
Routine hearing exams, hearing aids, and hearing aid services (including evaluation and fitting, repair, and batteries) | $0 cost to member for up to a $1,500 benefit per year |
No prior hospital stay is required
$0 cost to member days
1 through 100
Vaccines for COVID-19, pneumonia, influenza, and Hepatitis B
$0 cost to member
Many preventive services are covered, including an annual wellness visit, breast cancer screening, colorectal cancer screening, diabetes screening
$0 cost to member
Preventive and comprehensive dental services include oral exams, dentures, x-rays, extractions, fillings, and deep cleanings
$0 cost for up to $2,200
benefit for Ohio members,
$2,350 for Maryland members,
$1,750 for Indiana
members
Routine vision screening, lenses, frames, and/or contacts
$0 cost to member for up to $250 per year
Members may select from a catalog of products such as shampoo, lotion, deodorant, lip balm, socks, and more
$0 cost to member for up to $100 per month (OH & MD members) and $94 (IN members) (the unused amount does not roll over)
Routine hearing exams, hearing aids, and hearing aid services (including evaluation and fitting, repair, and batteries)
$0 cost to member for up to a $1,500 benefit per year
Last modified: 01/05/2023