2023 PSC HMO Individual Plan 1 EOC
| Description
|
In-network
|
| Deductible
|
N/A
|
| Out of Pocket Maximum
|
$4,000
|
| Coverage Gap
|
N/A
|
| Catastrophic
|
N/A
|
| Description
|
Included in OOP?
|
| Deductible
|
N/A
|
| Copayments
|
Yes
|
| Coinsurance
|
Yes
|
| Non-covered charges
|
No
|
| Medical drug copayments
|
Yes
|
| Prescription drug copayments
|
No
|
| Specialty drug copayments
|
Yes, if billed through medical
|
| Dental
|
Yes, if billed through medical
|
| Vision
|
Yes, if billed through medical
|
| Hearing
|
Yes, if billed through medical
No, if billed through TruHearing
|
| Code Grids
|
| Prior Authorization
|
Advanced Imaging Matrix
|
Specialty Medication
|
Preventive Grid
|
Allergy Testing and Treatment
| Description
|
Benefit In-network
|
PA Required?
|
| PCP
|
$0 copayment
|
See PA Grid
|
| Specialist
|
$50 copayment
|
See PA Grid
|
| Outpatient
|
$325 copayment
|
See PA Grid
|
Benefit Information
- Covered services include:
- Allergy injections
- Allergy evaluation and testing
- Allergy testing and treatment materials administered during a covered visit
- Medically-necessary medical care or surgery services furnished in a physician’s office, certified ambulatory surgical center, hospital outpatient department,or any other location.
- Consultation, diagnosis, and treatment by a specialist.
- Injection limit of 120 units per rolling year for CPT code 95165.
Ambulance
Autism Spectrum Disorder
Bariatric Surgery
Cancer Clinical Trials
Category:Medicare Benefits