![]() $0 copay for a Mobile PERS plus device equipped with two-way voice communication, GPS location technology, and the option of auto fall detection with 24/7 monitoring Personal Emergency Response System (PERS) If you are outside of the United States or its territories, your worldwide emergency and urgent care coverage is limited to $50,000 You may receive covered emergency and urgent care services anywhere in the world. $0 copay for up to a maximum of $200 each year for routine corrective eyeglasses (lenses and frames) or contact lenses Once your yearly out-of-pocket drug costs total $7,400, you will pay the greater of either a 5% coinsurance or $.15 for generic drugs and $10.35 for all other drugs. Select Insulins are identified with “SI”. To find out which drugs are Select Insulins, please review the McLaren Medicare Formulary. Under this plan, during the Initial Coverage Stage and Coverage Gap Stage, your out-of-pocket costs for Select Insulins will be $10 - $35. For brand name drugs, you will pay 25% of the price plus a portion of the dispensing fee. For all other generics, you will pay 25% of the price. Once your total drug cost (what you pay plus what we pay) reaches $4,660, you will move into the Coverage Gap Stage where you will continue to pay your copay for drugs on Tier 1 and Tier 6. $0 copay for up to 30 one-way non-emergency trips per year to plan approved health-related locations. Annual limit of 5 discharges for a total of 140 meals per year. $0 copay for 28 meals (2 meals per day for 14 days) delivered directly to your home after each discharge from an inpatient acute or a skilled nursing facility stay. Benefit is limited to TruHearing’s Advanced and Premium hearing aids. Up to two TruHearing-branded hearing aids, one per ear every two years. $50 additional cost per aid for optional hearing aid rechargeability $0 copay for up to a maximum of $100 each year for routine corrective eyeglasses (lenses and frames) or contact lenses $40 copay for Medicare-covered dental services Periodontal non-surgical procedures (covered once per quadrant per 24-month period).One set of bitewing X-rays each year (not payable in the same calendar year as a full mouth X-ray).2 exams and 2 cleanings (regular or periodontal) each year. ![]() $50 copay anywhere in the United States or its territoriesĭiagnostic radiology services (MRI, CT scan) $95 copay anywhere in the United States or its territories Outpatient surgery - ambulatory surgical center
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