Presbyterian Dual Plus (HMO D-SNP)
Health Insurance Company: Presbyterian Health Plan
Medicare Advantage Plan Details
Medicare-Medicaid Dual Eligible (D-SNP)
- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Emergency Room
0% or 20% coinsurance per visit (always covered)
Ambulance Coverage
0% or 20% coinsurance
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: 0% or 20% coinsurance
Medicare-covered lab services: 0% or 20% coinsurance
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): 0% or 20% coinsurance
Medicare-covered x-ray services: 0% or 20% coinsurance
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: 0% or 20% coinsurance per visit
Hospitalization Coverage
Inpatient hospital-acute:
In 2024 the amounts for each benefit period are $0 or:
$1,632 deductible for days 1 through 60
$408 copay per day for days 61 through 90
Inpatient hospital psychiatric:
In 2024 the amounts for each benefit period are $0 or:
$1,632 deductible for days 1 through 60
$408 copay per day for days 61 through 90
Rehabilitation Coverage
Occupational therapy services:
0% or 20% coinsurance
Physical therapy and speech and language therapy services:
0% or 20% coinsurance
Urgent Care Coverage
0% or 20% coinsurance per visit (always covered)
Skilled Nursing Facility (SNF)
In 2024 the amounts for each benefit period are $0 or:
$0 copay for days 1 through 20
$204 copay per day for days 21 through 100
Mental Health Coverage
Medicare-covered individual sessions: 0% or 20% coinsurance
Medicare-covered group sessions: 0% or 20% coinsurance
Dental, Vision, Hearing Benefits
Dental Services
Oral exams: $0 copay
Prophylaxis (cleaning): $0 copay
Dental x-rays: $0 copay
Vision Benefits
Eye exams:
Routine eye exams: $0 copay
Eyewear:
Contact Lenses: $0 copay
Eyeglasses: $0 copay
Hearing Benefits
Hearing exams:
Routine hearing exams: 0% or 20% coinsurance
Hearing aids:
Hearing aids (all types): $0 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$60.00 copay (90-day supply)
Tier 3: Preferred Brand
18% coinsurance (30-day supply)
18% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
48% coinsurance (30-day supply)
48% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$60.00 copay (90-day supply)
Tier 3: Preferred Brand
18% coinsurance (30-day supply)
18% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
48% coinsurance (30-day supply)
48% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Plan Links
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