HMH20000 - 2023 PSC Plan 1

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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.


Autism Spectrum Disorder

Bariatric Surgery

Cancer Clinical Trials

Category:Medicare Benefits