MCS Classicare Patriot (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

Durable Medical Equipment (DME)

• Authorization Required: Yes
• Preferred Vendors: Yes

Prosthetics/Orthotics – Orthotic Devices

• Coinsurance: 0% – 20%

Prosthetics/Orthotics – Orthotic Devices

• Coinsurance: 10%
• Specified Manufacturers: Yes
• Limits Apply: Yes

Emergency and Urgent Care Services

Urgently Needed Services

• Copay: $40.00
• Enhanced Benefits: Worldwide Emergency Coverage; Worldwide Urgent Coverage
• Waivers if Admitted: Yes

Worldwide Urgent Coverage

• Copay: $75.00

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

Contact Lenses

• Limits Apply: Yes

Eyeglasses (Lenses and Frames)

• Limits Apply: Yes

Eyeglass Lenses

• Limits Apply: Yes

Eyeglass Frames

• Limits Apply: Yes

Health Care Professional Services

Chiropractic Services

• Enhanced Benefits: Routine Care

Routine Chiropractic Care

• Limits Apply: No

PT and SP Services

• Authorization Required: Yes
• Referral Required: No

Hearing Exams and Hearing Aids Services

Hearing Exams

• Enhanced Benefits: Routine Hearing Exams; Fitting/Evaluation for Hearing Aid

Routine Hearing Exams

• Limits Apply: No

Fitting/Evaluation for Hearing Aid

• Limits Apply: No

Hearing Aids

• Authorization Required: No
• Referral Required: No
• Enhanced Benefits: Hearing Aids (all types)

Hearing Aids (All Types)

• Authorization Required: Yes
• 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

Inpatient Hospital Psychiatric Services

Inpatient Hospital-Psychiatric

• Authorization Required: Yes
• Referral Required: No

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

• Coinsurance: 0% – 20%
• Authorization Required: Yes

Non-Primarily Health Related Benefits for the Chronically Ill

General Supports for Living

• Authorization Required: No
• Referral Required: No

Transportation for Non-Medical Needs

• Limits Apply: No

General Supports for Living

• Authorization Required: No
• Referral Required: No

Transportation for Non-Medical Needs

• Limits Apply: No

Other Non-Primarily Health Related Benefits for the Chronically Ill

13i-O2(NMC)

• Authorization Required: No
• Referral Required: No

13i-O2(NMC)

• Authorization Required: No
• Referral Required: No

Out-of-Network Data for PPO Plans

Outpatient Clinical, Diagnostic, and Therapeutic Radiology Services

Outpatient Diagnostic Procedures/Tests

• Coinsurance: 0% – 20%

Outpatient Lab Services

• Coinsurance: 0% – 20%
• Authorization Required: Yes
• Referral Required: No

Outpatient Diagnostic Radiology

• Coinsurance: 0% – 20%

Outpatient Therapeutic Radiology

• Coinsurance: 0% – 20%

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

Outpatient Hospital Services – General

• Authorization Required: Yes

Outpatient Hospital Services – Observation

• Authorization Required: No
• Referral Required: No

Partial Hospitalization Services

Partial Hospitalization

• Authorization Required: No
• 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;14c7: Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)*;14c17: Alternative Therapies*;14c18: Therapeutic Massage;

Nutritional/Dietary Benefit

• Limits Apply: No

Alternative Therapies

• Limits Apply: No

Therapeutic Massage

• Limits Apply: No

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: No
• Referral Required: No

Skilled Nursing Facility (SNF) Services

SNF Medicare-covered stay

• Authorization Required: Yes
• Referral Required: No

Supplemental Benefits Preventive Services

Other Defined Supplemental Benefits

• Enhanced Benefits: 14c4: Fitness Benefit*;

14c4(NMC)

• Authorization Required: No
• Referral Required: No

Other Defined Supplemental Benefits

• Enhanced Benefits: 14c4: Fitness Benefit*;

14c4(NMC)

• Authorization Required: No
• Referral Required: No