Martin’s Point Generations Advantage Alliance (HMO)

Cardiac and Pulmonary Rehabilitation Services

Cardiac and Pulmonary Rehabilitation Services

• Authorization Required: Yes
• Referral Required: No

Durable Medical Equipment, Prosthetics/Orthotics, and Medical Supplies

Prosthetics/Medical Supplies

• Authorization Required: Yes
• Preferred Vendors: No

Prosthetics/Orthotics – Orthotic Devices

• Coinsurance: 10%

Prosthetics/Orthotics – Orthotic Devices

• Coinsurance: 10%
• Authorization Required: No
• Specified Manufacturers: No
• Limits Apply: No

Emergency and Urgent Care Services

Urgently Needed Services

• Copay: $125.00
• Enhanced Benefits: Worldwide Emergency Coverage; Worldwide Urgent Coverage; Worldwide Emergency Transportation
• Waivers if Admitted: Yes

Worldwide Emergency Transportation

• Copay: $125.00
• Limits Apply: No

Eye Exams and Eye Wear Services

Eye Exams

• Enhanced Benefits: Routine Eye Exams

Routine Eye Exams

• Limits Apply: No

Eyewear

• Authorization Required: No
• Referral Required: No
• Enhanced Benefits: Contact lenses; Eyeglasses (lenses and frames); Eyeglass lenses; Eyeglass frames; Upgrades

Contact Lenses

• Limits Apply: Yes

Eyeglasses (Lenses and Frames)

• Limits Apply: Yes

Eyeglass Lenses

• Limits Apply: Yes

Eyeglass Frames

• Limits Apply: Yes

Eyewear Upgrades

• Coinsurance: 20%

Health Care Professional Services

Chiropractic Services

• Enhanced Benefits: Routine Care

Routine Chiropractic Care

• Limits Apply: Yes

PT and SP Services

• Copay: $5.00
• Authorization Required: No
• Referral Required: No

Podiatry Services

• Copay: $0.00 – $5.00

Hearing Exams and Hearing Aids Services

Hearing Exams

• Enhanced Benefits: Fitting/Evaluation for Hearing Aid

Fitting/Evaluation for Hearing Aid

• Limits Apply: No

Hearing Aids

• Copay: $5.00
• Authorization Required: No
• Referral Required: Yes
• Enhanced Benefits: Hearing Aids (all types)

Hearing Aids (All Types)

• Referral Required: No
• Limits Apply: No

Home Health Services

Home Health Services

• Authorization Required: Yes
• Referral Required: No

Inpatient Hospital Acute Services

Inpatient Hospital-Acute

• Enhanced Benefits: Additional Days

Inpatient Acute Additional Days

• Limits Apply: Yes

Inpatient Hospital-Acute

• Authorization Required: Yes
• Referral Required: No
• Day Interval 1: $375.00 (Days 1 – 7)
• Day Interval 2: $0.00 (Days 8 – 90)

Inpatient Hospital Psychiatric Services

Inpatient Hospital-Psychiatric

• Authorization Required: Yes
• Referral Required: No
• Day Interval 1: $220.00 (Days 1 – 7)
• Day Interval 2: $0.00 (Days 8 – 90)

Medicare Part B Prescription Drugs

Medicare Part B Drugs – Tier 2

• Coinsurance: 0% – 20%

Medicare Part B Drugs – Tier 3

• Coinsurance: 0% – 20%

Medicare Part B Drugs – Tier 1

• Copay: $35.00
• Authorization Required: Yes

Non-Primarily Health Related Benefits for the Chronically Ill

Meals (Beyond limited basis)

• Limits Apply: Yes

General Supports for Living

• Authorization Required: Yes
• Referral Required: Yes

Out-of-Network Data for PPO Plans

Outpatient Blood, Acupuncture, and Other Services

Acupuncture

• Enhanced Benefits: Number of Treatments
• Limits Apply: Yes

Other 3

• Authorization Required: No
• Referral Required: Yes

Outpatient Clinical, Diagnostic, and Therapeutic Radiology Services

Outpatient Diagnostic Procedures/Tests

• Coinsurance: 0% – 5%

Outpatient Lab Services

• Copay: $0.00 – $5.00
• Coinsurance: 0% – 20%
• Authorization Required: Yes
• Referral Required: Yes

Outpatient Diagnostic Radiology

• Coinsurance: 20%

Outpatient Therapeutic Radiology

• Coinsurance: 20%

Outpatient X-Ray Services

• Coinsurance: 5%

Outpatient Hospital, ASC, Substance Abuse, and Cardiac Rehabilitation Services

Outpatient Hospital Services – General

• Copay: $0.00 – $275.00

Outpatient Hospital Services – Observation

• Copay: $275.00
• Authorization Required: Yes
• Referral Required: No

Partial Hospitalization Services

Partial Hospitalization

• Authorization Required: Yes
• Referral Required: No

Preventive Services (Health Education, Immunizations, Routine Physicals, Pap/Pelvic Exams)

Kidney Disease Education Services

• Authorization Required: No
• Referral Required: No

Other Defined Supplemental Benefits

• Enhanced Benefits: 14c1: Health Education;14c2: Nutritional/Dietary Benefit;14c3: Additional Sessions of Smoking and Tobacco Cessation Counseling;14c4: Fitness Benefit*;14c7: Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)*;14c8: Home and Bathroom Safety Devices and Modifications*;14c9: Counseling Services;14c11: Personal Emergency Response System (PERS);14c12: Medical Nutrition Therapy (MNT);14c15: Wigs for Hair Loss Related to Chemotherapy;14c16: Weight Management Programs*;14c17: Alternative Therapies*;

Nutritional/Dietary Benefit

• Limits Apply: Yes

Counseling Services

• Limits Apply: No

Alternative Therapies

• Authorization Required: Yes
• Limits Apply: Yes

Diabetes Self-Management Training – Level 1

• Authorization Required: No

Diabetes Self-Management Training – Level 2

• Authorization Required: No

Diabetes Self-Management Training – Level 3

• Authorization Required: No

Diabetes Self-Management Training – Level 4

• Authorization Required: No

Diabetes Self-Management Training – Level 5

• Authorization Required: No
• Referral Required: No

Renal Dialysis Services

Dialysis Services

• Coinsurance: 20%
• Authorization Required: Yes
• Referral Required: No

Skilled Nursing Facility (SNF) Services

SNF Medicare-covered stay

• Authorization Required: Yes
• Referral Required: No
• Day Interval 1: $10.00 (Days 1 – 20)
• Day Interval 2: $203.00 (Days 21 – 100)

Supplemental Benefits Preventive Services

Other Defined Supplemental Benefits

• Enhanced Benefits: 14c18: Therapeutic Massage;

Therapeutic Massage

• Authorization Required: No
• Referral Required: Yes
• Limits Apply: Yes

Other Defined Supplemental Benefits

• Enhanced Benefits: 14c1: Health Education;14c8: Home and Bathroom Safety Devices and Modifications*;

Home and Bathroom Safety Devices and Modifications

• Authorization Required: No
• Referral Required: No