HMH20001 - PSC Plan 2 w/Rx

2023 PSC HMO Individual Plan 2 EOC

Location of product	Effective Date	On or Off HIX	Multiplan
New Mexico	01/01/2023	N/A	No

Description	In-Network
Deductible	N/A
OOP	$4,500
Coverage Gap	$4,660
Catastrophic	$7,400

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

Allergy Testing and Treatment

Must be medically necessary. Always verify place of service.

2022 Benefit
Description	Benefit INN	PA Required
PCP	$5 copayment	See PA grid
Specialist	$50 copayment	See PA grid
Outpatient	$325 copayment	See PA grid

2023
Description	Benefit INN	PA Required
PCP	$0 copayment	See PA grid
Specialist	$45 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 material 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.

Limitations / Exclusions

• N/A

Ambulance

Must be medically necessary. Always verify place of service.

PHP Medical Policy - Ambulance Services

2022 Benefit
Description	Benefit INN/OON	PA Required
Ambulance	$250 copayment per one-way trip	See PA grid

2023
Description	Benefit INN/OON	PA Required
Ambulance	$250 copayment per one-way trip	See PA grid

Benefit Information

• Covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care only if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person's health or if authorized by the plan.
• We also cover the services of a licensed ambulance anywhere in the world without prior authorization including transportation through the 911 emergency response system where available if on of the following is true:
  • The member reasonably believes that the member has an emergency medical condition requires the clinical support of ambulance transport services.
  • The treating physician determines that the member must be transported to another facility because their emergency medical condition is not stabilized and the care they need is not available at the treating facility.
• Non-emergency transportation by ambulance is appropriate if it is documented that the member's condition is such that other means of transportation could endanger the person's health and that transportation by ambulance is medically required.

Limitations / Exclusions

• One copayment per trip when there is more than one trip in a single day.
• Copayment is not waived if admitted.
• The member may need to file a claim for reimbursement unless the out-of-network provider agrees to bill us.

Autism Spectrum Disorder

Must be medically necessary. Always verify place of service

PHP Medical Policy - Autism Spectrum Disorders: Diagnosis and Treatment

2022 Benefit
Description	Benefit	PA Required
Office Visit	Based on place of service	See PA grid

2023
Description	Benefit	PA Required
Office Visit	Based on place of service	See PA grid

Benefit Information

N/A

Limitations / Exclusions

N/A

Bariatric Surgery

Must be medically necessary. Always verify place of service.

PHP Medical Policy - Bariatric Surgery (Weight Loss Surgery) for Medicare

2022 Benefit
Description	Benefit INN	PA Required
Specialist	$50 copayment	See PA grid
Outpatient	$325 copayment	See PA grid
Inpatient	Days 1-5: $325 copayment per day There is no charge for the remainder of your covered hospital stay.	Yes
Mental Health	$0 copayment	See PA grid
Laboratory	$0 copayment	See PA grid

2023
Description	Benefit INN	PA Required
Specialist	$45 copayment	See PA grid
Outpatient	$325 copayment	See PA grid
Inpatient	Days 1-5: $325 copayment per day There is no charge for the remainder of your covered hospital stay.	Yes
Mental Health	$0 copayment	See PA grid
Laboratory	$0 copayment	See PA grid

Benefit Information

• Surgical treatment of morbid obesity (bariatric surgery) is covered only if it is medically necessary as defined in the plan agreement (as defined by PHP Policy).
  • Bariatric surgery is covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related comorbid medical conditions; and
  • Is a covered benefit only if a participant meets this criterion and all other requirements.
• Prior authorization may be required.

Limitations / Exclusions

N/A

Cancer Clinical Trials

Must be medically necessary. Always verify place of service.

PHP Medical Policy - Cancer Clinical Trials, Routine Patient Care Costs

2022 Benefit
Description	Benefit	PA Required
Cancer Clinical Trial	Copayment or coinsurance based on service provided	See PA grid

2023
Description	Benefit	PA Required
Cancer Clinical Trial	Copayment or coinsurance based on service provided.	See PA grid

Benefit Information

If the member is a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.

A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate.

An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life-threatening disease or condition and is:

• Conducted under an investigational new drug application reviewed by the Food and Drug Administration;
• A drug trial that is exempt from having such an investigational new drug application; OR
• Is approved or funded (which may include funding through in-kind contributions) by one or more of the following:
  • The National Institutes of Health;
  • The Centers for Disease Control and Prevention;
  • The Agency for Health Care Research and Quality;
  • The Centers for Medicare & Medicaid Services;
  • A cooperative group or center of any of the entities described in clauses (a) through (d) or the Department of Defense or the Department of Veterans Affairs;
  • A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants; OR
  • The Department of Veterans Affairs, the Department of Defense, or the Department of Energy, if the Secretary of Health and Human Services determines that the study has been reviewed and approved through a system of peer review that (i) is comparable to the system of peer review of studies and investigations used by the National Institutes of Health and (ii) assures unbiased review of the heist scientific standards by qualified individuals who have no interest in the outcome of the review.

Routine patient care costs that are covered are items or services that would be covered for a member or beneficiary who is not enrolled in a clinical trial. All applicable plan limitations for coverage of out-of-network care will still apply to routine patient costs in clinical trials.

Routine patient care costs do not include:

• The actual clinical trial or the investigational service itself;
• Cost of data collection and record keeping that would not be required but for the clinical trial; Items and services provided by the clinical trial sponsor without charge;
• Travel, lodging, and per diem expenses;
• A service that is clearly inconsistent with widely accepted and established standards for a particular diagnosis; and
• Any other services provided to clinical trial participants that are necessary only to satisfy the data collections needs of the clinical trial.

Limitations / Exclusions

Review Exclusions

Chiropractic, Acupuncture, Massage Therapy, Alternative Therapy

Must be medically necessary. Always verify place of service.

2022 Benefit
Description	Benefit INN	PA Required
Chiropractic Medicare Covered Manual manipulation of the spine to correct subluxation	$20 copayment	See PA grid
Chiropractic Routine Services 25 visits per calendar year.	$20 copayment	See PA grid
Acupuncture Office Visit Routine 25 visits per calendar year	$20 copayment	See PA grid
Acupuncture Office Visit for lower back pain 20 visits per calendar year	$20 copayment	See PA grid
Massage therapy	Not covered except when ordered as a part of physical therapy	See PA grid
Alternative therapy	Not covered	See PA grid

2023
Description	Benefit INN	PA Required
Chiropractic Medicare Covered Manual manipulation of the spine to correct subluxation	$20 copayment	See PA grid
Chiropractic Routine Services 25 visits per calendar year.	$20 copayment	See PA grid
Acupuncture office visit 45 visits per calendar year, combined between Medicare covered and Routine.	$20 copayment	See PA grid
Massage therapy	Not covered except when ordered as a part of physical therapy	See PA grid
Alternative therapy	Not covered	See PA grid

Benefit Information

Chiropractic services

We cover only manual manipulation of the spine to correct subluxation and routine chiropractic services.

• Medicare covered services have no visit limit.
• Routine chiropractic services have 25 visits per calendar year.

Acupuncture

• Routine visits have 25 visits per calendar year
• Visits for lower back pain: 12 visits in 90 days. Additional 8 if demonstrating improvement (20 total per calendar year).

The above verbiage is taken from the EOC. Claims are configured to pay all 45 acupuncture visits regardless of diagnosis and no additional documentation is required to demonstrate improvement.

Limitations / Exclusions

N/A

Dental Services

Must be medically necessary. Always verify place of service.

2022 Medical Dental Benefit
Description	Benefit INN	PA Required
Office Visit	$50 copayment	See PA grid
Outpatient	$325 copayment	See PA grid
Anesthesia for dental services	Included in copayment/coinsurance	See PA grid

2023 Medical Dental Benefit
Description	Benefit INN	PA Required
Office Visit	$45 copayment	See PA grid
Outpatient	$325 copayment	See PA grid
Anesthesia for dental services	Included in copayment/coinsurance	See PA grid

Medical Benefit Information

• In general, preventive dental services are not covered by Original Medicare.
• We cover non-routine dental care. Covered services by a dentist or oral surgeon are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease, or services that would be covered when provided by a medical provider.
• We cover medically-necessary services the member gets in the outpatient.

Medical Plan Limitations / Exclusions

Exclusions:

• Dental services for the care, treatment, removal (extraction) or replacement of teeth.
• Routine dental care, such as cleanings, fillings or dentures. However, non-routine dental care required to treat illness or injury may be covered as inpatient or outpatient care

Optional Dental Plan Benefits

DentaQuest Provider Directory

DentaQuest Contact Information

For Member Services
DentaQuest PHP Client Assistance: 1-800-720-5948 for PHP staff use only, Monday-Friday: 8am-6pm EST
DentaQuest will not speak with members. Do not provide DentaQuest's phone # to members. If a member has specific dental questions, contact DentaQuest on the members behalf for the requested information. Dental claims and prior authorizations are not located in HRP. Call DentaQuest for claim and prior authorization/utilization management review inquiries. Provide the Presbyterian member ID number to the DentaQuest representative.

For Provider Services
DentaQuest Provider Services: 1-855-343-4276, Monday-Friday 8am-5pm CT

DentaQuest Benefits

Description	Benefit
Preventive (basic) dental	No charge
Comprehensive Dental (if enrolled in it)	Minor Restorative- 20% coinsurance Major Restorative- 50% coinsurance

Preventive Dental Plan Benefit Information
Members receive the following Preventive Dental benefits at no charge automatically as this is built into the medical plan.
Oral Exam	Periodic oral evaluation, extensive oral exams, re-evaluation-limited problem focused - 2 every 12 months. Limited oral exams - 3 per 12 months. Comprehensive oral exam & comprehensive periodontal evaluation - one every 36 months per provider or location.
Cleanings	Prophylaxis, scaling in presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 months.
Dental X-Rays	Bitewings (one, two three four images) - 1 every 12 months. Intraoral complete series, Vertical bitewings, Panoramic radiographic image-one every 36 months. Intraoral periapical image. Intraoral occlusal radiographic image - 2 every 24 months.
Fluoride Treatments	Topical application of fluoride varnish, topical fluoride - 2 every 12 months.
Periodontal Maintenance	Periodontal maintenance procedures (following active therapy) 4 every 12 months.
Emergency Treatment of minor pain.
Palliative Treatment

Comprehensive Dental Plan Benefit Information
Members have the option to enroll in the Comprehensive Dental plan for an additional premium of $9 per month.
No deductible Members have a $4,000 Maximum calendar year benefit Annual maximum coverage is for comprehensive dental services performed in-network only The unused portion of the annual maximum does not carry forward to next year's benefit. Members can enroll at any time during the year. Benefits will begin on the 1st of the month. If member chooses to disenrolled during the year, they will not be able to re-enroll until January 1st of following year.
Minor Restoratives	Fillings Extractions Denture adjustments/repairs
Major Restoratives	Crowns Bridges Root Canals Dentures periodontics Anesthesia

COMPLETE LIST OF DENTAL PLAN BENEFITS
Dental Service	Benefit
Amalgam and Resin fillings, resin infiltration of incipient smooth surface lesion	20%, 1 per tooth surface/24 mos. In/Onlays-20%, 1 per tooth/60 mos.
Protective Restorations	20%, 1 per tooth/ lifetime.
Recement or re-bond inlay, onlay, partial restoration, crown	20%, 1 per tooth/24 mos.
Crowns, Core build-up, pin retention-per tooth, post and core	Each additional post-50%, 1 per tooth/60 mos.
Crown repair necessitated by restorative material failure	50%, 1 per 24 mos.
Pulpotomy and gross pulpal debridement of tooth	50%, 1 per tooth/lifetime.
Root canals and retreatment of previous root canal	50%, 1 per tooth/lifetime.
Apicoectomy/Periradicular surgery	50%, 1 per tooth/lifetime.
Retrograde fill	50%, 1 per tooth/lifetime.
Gingivectomy-gingivoplasty, gingival flap procedure, osseous surgergy	50%, 1 per quadrant/36 mos.
Clinical crown lengthening	50%, 1 per tooth/lifetime.
Periodontal scaling and root planing	50%, 1 per quadrant/36 mos.
Full mouth debridement	50%, 1 per 36 mos.
Extractions and coronectomy	20%, 1 per tooth/lifetime.
Oralantral fistula closure, primary closure of a sinus perforation	50%, 2 per arch/lifetime.
Alveoloplasty	50%, 1 per quadrant/lifetime.
Verstibuloplasty	50%, 1 per arch/lifetime.
Removal of lateral exostosis (maxilla or mandible)	50% 2 per arch/lifetime.
Removal of Torus Palantinus	50% once per lifetime.
Reduction of osseous tuberosity, removal of torus mandibularis	50% 2 per lifetime.
Frenulectomy, frenuloplasty, excision of hyperplastic tissue	50%, 1 per arch per lifetime.
Excision of periocornal gingiva	50%, 1 per tooth per lifetime.
Removable dentures-complete, partial, immediate, overdentures	50%, 1 per 60 mos.
Fixed partial dentures- pontics and retainers, retainer crowns	50%, 1 per 60 mos.
Adjust dentures	20%, two adjustments per arch/12 mos.
Repair dentures	20%, 1 per arch/12 mos.
Repair base or framework or replace missing or broken tooth or clasp, add tooth & clasp on dentures	20%, 1 per tooth 12 mos.
Rebase and reline dentures	20%, 1 per 36 mos.
Tissue conditioning	20%, 1 per 60 mos after new denture.
Re-cement, repairs of partial dentures	20%, 1 per 24 mos.
Surgical placement of implant, mini implant and abutments (retainers, crowns)	50%, 1 per 60 mos./quadrant.
Repair, re-cement, re-bond implant/abutment	20%, 1 per tooth per 24 mos.
Professional visits-house, extended care facility, hospital or ambulatory surgical center	50%, 1 per date of service, 6/year
Consultation	50%, 1 per provider/yr
Application of desensitizing medicament	50% 2 per 12 mos.
Occlusal analysis-mounted case, complete adjustment	50%, 1 per 60 mos.
Occlusal adjustment-limited	50%, 1 per 12 mos.

Diabetes Services

Must be medically necessary. Always verify place of service.

PHP Medical Policy Diabetic Equipment

2022 Diabetes Services Benefit
Description	Benefit INN	PA Required
Office Visit with Diabetic Diagnosis Diabetic Education Visit	No charge	See PA grid
Certified diabetes educator telephonic visits	No charge	See PA grid
Diabetic Supplies Purchased through a Durable Medical Equipment provider	No charge	See PA grid

2023
Description	Benefit INN	PA Required
Office Visit with Diabetic Diagnosis Diabetic Education Visit	No charge	See PA grid
Certified diabetes educator telephonic visits	No charge	See PA grid
Diabetic Supplies Purchased through a Durable Medical Equipment provider	No charge	See PA grid

Benefit Information

Diabetes Services

Covered Benefits are provided if the member has insulin dependent (Type I) diabetes, non-insulin dependent (Type 2) diabetes, and elevated blood glucose levels induced by pregnancy (gestational diabetes). We will guarantee Coverage for the equipment, appliances, Prescription Drug/Medications, insulin or supplies that meet the United States Food and Drug Administration (FDA) approval, and are the medically accepted standards for diabetes treatment, supplies and education.

Diabetes Education

The following benefits are available when received from a practitioner/provider who is approved to provide diabetes education:

• Medically necessary visits upon the diagnosis of diabetes.
• Visits following a practitioner/provider diagnosis that represents a significant change in condition or symptoms requiring changes in the patient's self-management.
• Visits when re-education or refresher training is prescribed by a health care practitioner/provider with prescribing authority.
• Telephonic visits with a Certified Diabetes Educator.
• Medical nutrition therapy related to diabetes management.

Approved diabetes educators must be part of our in-network practitioners/providers who are registered, certified or licensed health care professional with recent education in diabetes management.

Diabetes Supplies and Services

The following equipment, supplies, appliances, and services are covered when prescribed by the member's practitioner/provider and when obtained through the designated network Provider:

• Insulin pumps when Medically Necessary, prescribed by an In-network endocrinologist
• Specialized monitors/meters for the legally blind
• Medically Necessary Covered Podiatric appliances for prevention of feet complications associated with diabetes. Refer to the Durable Medical Equipment Benefits Section.
• Preferred Prescriptive diabetic oral agents for controlling blood sugar levels
• Glucagon emergency kits
• Preferred Insulin
• Syringes
• Injection aids, including those adaptable to meet the needs of the legally blind
• Preferred Blood glucose monitors/meters
• Preferred Test strips for blood glucose monitors
• Preferred Lancets and lancet devices
• Preferred Continuous Glucose Monitoring (CGM) including system, sensor, and transmitter.
• Visual reading urine ketone strips

Limitations / Exclusions

Review exclusions

Diagnostic

Must be medically necessary. Always verify place of service.

2022 Benefit
Description	Benefit INN	PA Required
Labs, outpatient diagnostic and therapeutic radiological services	No charge	See PA grid
X-ray and Ultrasound	$20 copayment	See PA grid
MRI, MRA, CT and PET scans	$300 copayment	See Advanced Imaging Utilization Review Matrix
Inpatient	Included in inpatient copayment	Yes

2023
Description	Benefit INN	PA Required
Labs, outpatient diagnostic and therapeutic radiological services	No charge	See PA grid
X-ray and Ultrasound	$20 copayment	See PA grid
MRI, MRA, CT and PET scans	$300 copayment	See Advanced Imaging Utilization Review Matrix
Inpatient	Included in inpatient copayment	Yes

Benefit Information

Covered services include, but are not limited to:

• X-rays
• Radiation (radium and isotope) therapy including technician materials and supplies
• Surgical supplies, such as dressings
• Splints, casts and other devices used to reduce fractures and dislocations
• Laboratory tests
• Blood -including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need.
• Diagnostic Mammogram
• Other outpatient diagnostic tests.
  • MRI (Magnetic Resonance Imaging), MRA (Magnetic Resonance Angiogram), CT (Computed Tomography) and PET (Positron Emission Tomography)

Limitations / Exclusions

N/A

Dialysis

Must be medically necessary. Always verify place of service.

2022 Benefit
Description	Benefit INN	PA Required
Dialysis Services Outpatient or Home	20% coinsurance	See PA grid
Inpatient	Days 1-5: $325 copayment per day There is no charge for the remainder of your covered hospital stay	Yes
Part B drugs	20% coinsurance	See specialty grid

2023
Description	Benefit INN	PA Required
Dialysis Services Outpatient or Home	20% coinsurance	See PA grid
Inpatient	Days 1-5: $325 copayment per day There is no charge for the remainder of your covered hospital stay	Yes
Part B drugs	20% coinsurance	See specialty grid

Benefit Information

Covered services include

• Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime.
• Outpatient dialysis treatments including dialysis treatments when temporarily out of the service area.
• Inpatient dialysis treatments if you are admitted as an inpatient to a hospital for special care.
• Self-dialysis equipment
  • Includes training for the member and anyone helping them with their home dialysis treatments.
• Home dialysis equipment and supplies.
• Certain home support services such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check the dialysis equipment and water supply).
• Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, topical anesthetics, and erythropoiesis-stimulating agents.

Limitations / Exclusions

Inpatient: No limit to the number of days covered by the plan for each stay.

Durable Medical Equipment

Must be medically necessary. Always verify place of service.

Alternating Electromagnetic Field Therapy for Glioblastoma

Micellaneous

Orthotics and Prosthetics

Pneumatic Compression Devices

Rehabilitation and Mobility Devices

Respiratory Devices

• Verify type of equipment or supply. This is to ensure the equipment or supply they are requesting is a covered benefit.

2022 Benefit
Description	Benefit INN	PA Required
DME	20% coinsurance	See PA grid
Ostomy supplies	No charge	See PA grid
Therapeutic shoes and inserts	20% coinsurance	See PA grid
Diabetic lancets	No charge	See PA grid
Diabetic test strips	No charge	See PA grid
Diabetic glucose monitors	No charge	See PA grid

2023
Description	Benefit INN	PA Required
DME	20% coinsurance	See PA grid
Ostomy supplies	No charge	See PA grid
Therapeutic shoes and inserts	20% coinsurance	See PA grid
Diabetic lancets	No charge	See PA grid
Diabetic test strips	No charge	See PA grid
Diabetic glucose monitors	No charge	See PA grid

Benefit Information

Covered items include, but are not limited to:

• Wheelchairs, crutches, hospital bed, IV infusion pump, oxygen equipment, nebulizers, and walker.
• We cover all medically necessary durable medical equipment covered by Original Medicare. If our supplier in your area does not carry a particular brand or manufacturer, you may ask them if they can special order it for you.
• Prosthetic devices and related supplies
  • Devices (other than dental) that replace all or part of a body part or function. These include, but are not limited to:
  • Artificial limbs
  • Braces
  • Breast prostheses including a surgical brassiere after a mastectomy
  • Colostomy bags and supplies directly related to colostomy care
  • Includes certain supplies related to prosthetic devices, and repair and/or replacement of prosthetic devices.
  • Pacemakers
  • Prosthetic shoes. One pair per calendar year for diabetics of therapeutic custom-molded shoes including inserts provided with such shoes and two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts not including the non-customized removable inserts provided with such shoes. Coverage includes fitting.

Limitations / Exclusions

Exclusions:

• Disposable supplies for home use, such as bandages, gauze tape, antiseptics, dressings, ace-type bandages, and diapers, underpads, and other incontinence supplies, unless covered by Medicare; for example, ostomy or diabetic supplies.
• Exercise equipment.
• Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of the brace or the shoes are for a person with diabetic foot disease.
• Eyewear items that do not require a prescription by law (other than eyeglass frames), such as eyeglass holders, eyeglass cases, and repair kits.

Emergency Room

Must be medically necessary. Always verify place of service.

2022 Benefit
Description	Benefit INN/OON	PA Required
Emergency Room	$90 copayment	See PA grid
Worldwide ER Services	$90 copayment	N/A
Observation	$90 copayment	See PA grid

2023
Description	Benefit INN/OON	PA Required
Emergency Room	$110 copayment, waived if member is admitted inpatient	See PA grid
Worldwide ER Services	$110 copayment, waived if member is admitted inpatient	N/A
Observation	$110 copayment, waived if member is admitted inpatient	See PA grid

Benefit Information

Emergency care refers to services that are:

• Furnished by a provider qualified to furnish emergency services, and needed to evaluate or stabilize an emergency medical condition.
• A medical emergency is when the member, or any other prudent layperson with an average knowledge of health and medicine, believes that they have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.
• If you receive emergency care at an out-of-network hospital and need inpatient care after your emergency condition is stabilized, you must return to a network hospital in order for your care to continue to be covered or you must have your inpatient care at the out-of-network hospital authorized by the plan and your cost is the highest cost-sharing you would pay at a network hospital.
• Worldwide emergency care coverage.
• Worldwide services are paid through a member's claims reimbursement.

Outpatient Hospital Observation

• For outpatient hospital observation services to be covered, they must meet the Medicare criteria and be considered reasonable and necessary. Observation services are covered only when provided by the order of a physician or another individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or order outpatient tests.
• Note: Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an "outpatient." If you are not sure if you are an outpatient, you should ask the hospital staff.

Limitations / Exclusions

• If you are admitted to the hospital within 24 hours, you do not have to pay your emergency room copayment.
• The plan will not cover the excluded services even if they receive the services at an emergency facility, the excluded services are still not covered.
• The member may need to file a claim for reimbursement unless the provider agrees to bill us.

Genetic Counseling

Must be medically necessary. Always verify place of service.

2022 Benefit
Description	Benefit INN	PA Required
PCP Office Visit	$5 copayment	See PA grid
Specialist Office Visit	$50 copayment	See PA grid
Testing	No charge	Yes

2023
Description	Benefit INN	PA Required
PCP Office Visit	$0 copayment	See PA grid
Specialist Office Visit	$50 copayment	See PA grid
Testing	No charge	Yes

Benefit Information

• Genetic Counseling in support of anticipated genetic testing or to discuss the results of genetic testing.
• Genetic Testing is covered based on medical necessity.

Limitations / Exclusions

N/A

Gym

2022 Benefit
Description	Benefit INN	PA Required
Fitness Centers	No charge	N/A

2023
Description	Benefit INN	PA Required
Fitness Centers	No charge	N/A

Benefit Information

Member is covered for the following:

• Health Education Program:
  • We cover a variety of health education counseling programs and materials to help the member take an active role in protecting and improving your health, including programs for chronic medical conditions, nutrition, obesity, stress management, and tobacco-cessation.

• Wellness program: Healthways SilverSneakers® Fitness Center Memberships: A health and fitness benefit is provided through Healthways SilverSneakers®, fitness program that includes the following:
  • A basic fitness membership with access to all participating fitness membership with access to all participating fitness locations and their basic amenities.
  • SilverSneakers® group fitness classes, taught by certified instructors that focus on cardiovascular health, muscle strengthening, flexibility, agility, balance and coordination.
  • Health education events and social activities focused on overall well-being.
  • Access to www.silversneakers.com/member, a secure online community for members only, with wellness advice and fitness support information.
  • SilverSneakers® steps, self-directed fitness program for members without convenient access to SilverSneakers fitness locations, which includes tools and resources to help the member get fit at home or on the go.

For more information please visit www.silversneakers.com or call toll free 1-888-423-4632 Monday through Friday 8 a.m. to 8 p.m. (EST). The member can also go to a participating fitness location and show their Presbyterian Senior Care HMO membership card to enroll in the program.

Limitations / Exclusions

Non-covered services include, but are not limited to:

• Program, services, and facilities that carry additional charges, such as racquetball, tennis and some court sports, massage therapy, lessons related to recreational sports, tournaments, personal trainers, exercise equipment, and similar fee-based activities

Hearing

Must be medically necessary. Always verify place of service.

PHP Medical Policy - Bone Anchored Hearing Aid (BAHA)

2022 Medical Benefit
Description	Benefit INN	PA Required
Specialist Office Visit For Contracted Audiologists or other medical Specialists. If member needs hearing aids, member must use TruHearing providers to use their benefits.	$50 copayment	See PA grid

2023 Medical Benefit
Description	Benefit INN	PA Required
Specialist Office Visit For Contracted Audiologists or other medical Specialists. If member needs hearing aids, member must use TruHearing providers to use their benefits.	$45 copayment	See PA grid

2022 TruHearing Benefit
Description	Benefit INN	PA Required
Routine and Medicare Covered Hearing Exam	$0 copayment	See PA grid
TruHearing initial hearing exam	$0 copayment	Hearing exams must be scheduled through TruHearing to utilize benefit
TruHearing Advanced 19 32 channels, 6 programs	$699 copayment per aid Benefit doesn't apply to the member's out of pocket maximum	Must be purchased through a TruHearing provider to utilize benefit
TruHearing Premium 19 48 channels, 6 programs Rechargeable battery upgrade option 19 RIC Li for $75 per aid	$999 copayment per aid Benefit doesn't apply to the member's out of pocket maximum	Must be purchased through a TruHearing provider to utilize benefit

2023 TruHearing Benefit
Description	Benefit INN	PA Required
Routine and Medicare Covered Hearing Exam	$0 copayment	See PA grid
TruHearing initial hearing exam	$0 copayment	Hearing exams must be scheduled through TruHearing to utilize benefit
TruHearing Advanced 19 32 channels, 6 programs	$699 copayment per aid Benefit doesn't apply to the member's out of pocket maximum	Must be purchased through a TruHearing provider to utilize benefit
TruHearing Premium 19 48 channels, 6 programs Rechargeable battery upgrade option 19 RIC Li for $75 per aid	$999 copayment per aid Benefit doesn't apply to the member's out of pocket maximum	Must be purchased through a TruHearing provider to utilize benefit

Benefit Information

Benefit is administered by TruHearing.

• Warm transfer member to 1-866-202-0145.
• Customer Phone number is 1-866-202-0110.
• Member must arrange appointments through TruHearing to use these benefits. Any follow ups can be scheduled directly with the providers office.

TruHearing Benefits Include:

• Three in-person follow up visits for fitting and adjustments for the first year.
• Three year warranty for loss and damage.
• 60 day trial period.
• 80 free batteries per aid included with non-rechargeable models.

If a member inquires about hearing aid warranty through TruHearing, see below:

TruHearing Aid Warranty
Question	Answer
If a members hearing aids break, can the member use the warranty if it is still active?	TruHearing aids come with a 3 year warranty that also comes with a one-time loss or damage replacement. The member will need to contact the providers office to advise of the loss or damage. The provider will process the loss or damage replacement or the warranty for the member. When the Provider completes this request to the manufacturer, they must state that this is a TruHearing Patient.
Is there a handling fee (or any fee) associated with the warranty or in general for a member?	Loss and Damage fees differ per manufacturer, but the fees are lower when the Provider processes under TruHearing. Some manufactures apply a shipping charge others do not. There is no restocking fees assessed as long as the device(s) / hearing aid(s) are returned within the 60-day trial period. Once it falls outside of the 60 day trial period, there is a restocking fee charged.

Limitations / Exclusions

Benefit does not include or cover any of the following:

• Ear molds
• Hearing aid accessories
• Additional provider visits
• Extra batteries
• Hearing aids that are not TruHearing-branded hearing aids
• Costs associated with loss & damage warranty claims
• Costs associated with excluded items are the responsibility of the member and not covered by the plan
• Hearing aid copayments are not subject to the out-of pocket maximum.

Home Health

Must be medically necessary. Always verify place of service.

2022 Benefit
Description	Benefit INN	PA Required
Home	No charge	See PA grid
Home Health Aide	No charge	See PA grid
Homemaker Services	Not covered	See PA grid

2023
Description	Benefit INN	PA Required
Home	No charge	See PA grid
Home Health Aide	No charge	See PA grid
Homemaker Services	Not covered	See PA grid

Benefit Information

• Prior to receiving home health services, a doctor must certify that the member needs home health services and will order home health services to be provided by a home health agency. They must be home bound, which means leaving home is a major effort.
• Covered services include, but are not limited to:
  • Part-time or intermittent skilled nursing and home health aide services
  • Physical therapy, occupational therapy, and speech therapy
  • Medical and social services
  • Medical equipment and supplies
  • Home infusion including chemotherapy
  • Tele-monitoring
• Home health care services are provided by Presbyterian Home Health. If another agency is referred, that agency needs to be a part of the Presbyterian network and services require prior authorization through Presbyterian's Home Health state wide network.

Note: There is no cost-sharing for medical equipment and supplies covered under the home health benefit in accord with Medicare guidelines. However, the applicable cost-sharing listed elsewhere in the medical benefits chart will apply if they item is covered under a different benefit, for example durable medical equipment and related supplies.

For discounts on non medical home services visit: Benefit Source

Limitations / Exclusions

• To be covered under the home health care benefit, their skilled nursing and home health aide services combined must total fewer than 8 hours per day and 35 hours per week.
  • A home health aide cannot provide the services by himself or herself, a nurse needs to be present.

Exclusions:

• Custodial care is care provided in a nursing home, hospice, or other facility setting when you do not require skilled medical care or skilled nursing care. Custodial care is personal care that does not require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing.
• Personal care attendant
• Personal care service (PCS)
• Full-time nursing care in your home.
• Homemaker services include basic household assistance, including light housekeeping or light meal preparation.
• Meals delivered to your home, unless authorized as part of the Readmission Prevention Program described in the Medical Benefits Chart.

Hospice

Must be medically necessary. Always verify place of service.

2022 Benefit
Description	Benefit INN	PA Required
Hospice At home or in a facility	No charge	See PA grid

2023
Description	Benefit INN	PA Required
Hospice At home or in a facility	No charge	See PA grid

Benefit Information

Hospice Care: You may receive care from any Medicare-certified hospice program. Your hospice doctor can be a network provider or an out-of-network provider. Covered services include:

• Counseling Services performed by licensed social workers and chaplains
• DME equipment related to your terminal diagnosis
• Drugs for symptom control and pain relief related your terminal diagnosis
• Home care
• Nursing and Physician Services
• Short-term respite care

For hospice services and for services that are covered by Medicare Part A or B and are related to your terminal condition: While you are in the hospice program, your hospice provider will bill Presbyterian Senior Care.

For services that are covered by Medicare Part A or B and are not related to your terminal condition: If you need non-emergency, non-urgently needed services that are covered under Medicare Part A or B and that are not related to your terminal condition, your cost for these services depends on whether you use a provider in our plan's network: If you obtain the covered services from a network provider, you only pay the plan cost-sharing amount for in-network services If you obtain the covered services from an out-of-network provider, you pay the cost sharing under Fee-for-Service Medicare (Original Medicare)

For services that are covered by our plan but are not covered by Medicare Part A or B: We will continue to cover plan-covered services that are not covered under Part A or B whether or not they are related to your terminal condition. You pay your plan cost-sharing amount for these services.

Drugs are never covered by both hospice and our plan at the same time. If you are enrolled in Medicare hospice and require an anti-nausea, laxative, pain medication or anti-anxiety drug that is not covered by your hospice because it is unrelated to your terminal illness and related conditions, our plan must receive notification from either the prescriber or your hospice provider that the drug is unrelated before our plan can cover the drug. To prevent delays in receiving any unrelated drugs that should be covered by our plan, you can ask your hospice provider or prescriber to make sure we have the notification that the drug is unrelated before you ask a pharmacy to fill your prescription.

Note: If you need non-hospice care (care that is not related to your terminal condition), you should contact us to arrange the services. Getting your non-hospice care through our network providers will lower your share of the costs for the services. Our plan covers hospice consultation services (one time only) for a terminally ill person who hasn't elected the hospice benefit.

Limitations / Exclusions

N/A

Infertility

Must be medically necessary. Always verify place of service.

BCG Infertility

2022 Benefit
Description	Benefit INN	PA Required
Office Visit	Not covered	See PA grid
Outpatient	Not covered	See PA grid
Pharmacy	Not covered	See PA grid

2023
Description	Benefit INN	PA Required
Office Visit	Not covered	See PA grid
Outpatient	Not covered	See PA grid
Pharmacy	Not covered	See PA grid

Benefit Information

N/A

Limitations / Exclusions

Exclusion: All services related to artificial insemination and conception by artificial means, such as:

• Ovum transplants
• GIFT (Gamete Intrafallopian Transfer)
• Semen, Eggs and services related to their procurement and storage.
• IVF (Invitro Fertilization)
• ZIFT (Zygote Intrafallopian Transfer)

Inpatient

Must be medically necessary. Always verify place of service.

2022 Benefit
Description	Benefit INN	PA Required
Inpatient Includes acute care	Days 1-5: $325 copayment per day There is no charge for the remainder of your covered hospital stay	Yes

2023
Description	Benefit INN	PA Required
Inpatient	Days 1-5: $325 copayment per day There is no charge for the remainder of your covered hospital stay	Yes

Benefit Information

• Inpatient hospital care:
  • Includes inpatient acute, inpatient rehabilitation, and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last inpatient day.
• Covered services include but are not limited to:
  • Semi-private room or a private room if medically necessary
  • Meals including special diets
  • Regular nursing services
  • Costs of special care units such as intensive care or coronary care units
  • Drugs and medications
  • Lab tests
  • X-rays and other radiology services
  • Necessary surgical and medical supplies
  • Use of appliances, such as wheelchairs
  • Operating and recovery room costs
  • Physical, occupational, and speech language therapy
  • Inpatient substance abuse services
  • Blood - including storage and administration. Coverage of whole blood and packed red cells begins only with the first pint of blood that you need
  • Physician services

Limitations / Exclusions

If you get authorized inpatient care at an out-of-network hospital after your emergency condition is stabilized, your cost is the highest cost-sharing you would pay at a network hospital.

Note: If you are admitted to the hospital in 2020 and are not discharged until sometime in 2021, the 2020 cost-sharing will apply to that admission until you are discharged from the hospital or skilled nursing facility.

Note: To be an inpatient, your provider must write an order to admit you formally as an inpatient of the hospital. Even if you stay in the hospital overnight, you might still be considered an outpatient." If you are not sure if you are an inpatient or an outpatient, you should ask the hospital staff.

• There is no limit to the number of days covered by the plan based on medical necessity.

A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row.

Long Term Care

2022 Benefit
Description	Benefit INN	PA Required
Long Term Care	Not Covered	See PA grid

2023
Description	Benefit INN	PA Required
Long Term Care	Not Covered	See PA grid

Benefit Information

N/A

Maternity

Must be medically necessary. Always verify place of service.

PHP Medical Policy - Genetic Testing for Non-Invasive Prenatal Testing (NIPT)

PHP Medical Policy - Obstetric Ultrasound, 3D, 4D or 5D

2022 Benefit
Description	Benefit INN	PA Required
In-office PCP	$5 copayment	See PA grid
In-office Specialist	$50 copayment	See PA grid
Lab services	No charge	See PA grid
Ultrasound	No charge	See PA grid
Outpatient	$325 copayment	See PA grid
Inpatient	Days 1-5: $325 copayment per day There is no charge for the remainder of your covered hospital stay	Yes
Home birth	Not covered	See PA grid

2023
Description	Benefit INN	PA Required
In-office PCP	$0 copayment	See PA grid
In-office Specialist	$45 copayment	See PA grid
Lab services	No charge	See PA grid
Ultrasound	No charge	See PA grid
Outpatient	$325 copayment	See PA grid
Inpatient	Days 1-5: $325 copayment per day There is no charge for the remainder of your covered hospital stay	Yes
Home birth	Not covered	See PA grid

Benefit Information

• Outpatient hospital services
  • We cover medically-necessary services a member gets in the outpatient department of a hospital for diagnosis or treatment of an illness or injury.
• Covered services include, but are not limited to:
  • Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery.
• Inpatient hospital care:
  • Includes inpatient acute, inpatient rehabilitation, and other types of inpatient hospital services. Inpatient hospital care starts the day the member is formally admitted to the hospital with a doctor’s order. The day before they are discharged is their last inpatient day.
• Covered services include but are not limited to:
  • Semi-private room or a private room if medically necessary
  • Meals including special diets
  • Regular nursing services
  • Costs of special care units such as intensive care or coronary care units
  • Drugs and medications
  • Lab tests
  • X-rays and other radiology services
  • Necessary surgical and medical supplies
  • Use of appliances, such as wheelchairs
  • Operating and recovery room costs
  • Physical, occupational, and speech language therapy
  • Inpatient substance abuse services
  • Blood - including storage and administration. Coverage of whole blood and packed red cells begins only with the first pint of blood that you need
  • Physician services

Limitations / Exclusions

If you get authorized inpatient care at an out-of-network hospital after your emergency condition is stabilized, your cost is the cost-sharing you would pay at a network hospital.

Note: If you are admitted to the hospital in 2020 and are not discharged until sometime in 2021, the 2020 cost-sharing will apply to that admission until you are discharged from the hospital or skilled nursing facility.

Note: To be an inpatient, your provider must write an order to admit you formally as an inpatient of the hospital. Even if you stay in the hospital overnight, you might still be considered an outpatient.” If you are not sure if you are an inpatient or an outpatient, you should ask the hospital staff.

Medical Drug

Must be medically necessary. Always verify place of service.

2022 Benefit
Description	Benefit INN	PA Required
ROW1/COL1	ROW1/COL2	ROW1/COL3
ROW2/COL1	ROW2/COL2	ROW2/COL3
ROW3/COL1	ROW3/COL2	ROW3/COL3