Compare 2020 Medicare Health Plans
Home Medicare Plans Puerto Rico Luquillo County
Monday, January 20, 2020

Medicare y Mucho Mas - ELITE (HMO-POS)
(H4003-001)

by Medicare y Mucho Más - Luquillo County, PR
  • The plan offers national in-network prescription coverage. This means that you will pay the same amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
Contact Information

Mmm Healthcare Inc.
350 Chardon Avenue
San Juan, PR 00918

Phone: 1-787-620-2397
Toll free: 1-866-333-5470

Website
http://www.mmm-pr.com

/* 300x250 Text MedHPC */
Compare Plan Plan details
Plan Rating2.5 out of 5 stars
Premium and Other Important Information$0 monthly plan premium in addition to your monthly Medicare Part B premium.
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
$3 250 out-of-pocket limit. All plan services included.
$3 250 out-of-pocket limit. All plan services included.
$3 250 out-of-pocket limit. All plan services included.
Doctor and Hospital ChoiceNo referral required for network doctors specialists and hospitals.
Inpatient Hospital CareNo limit to the number of days covered by the plan each hospital stay.
For Medicare-covered hospital stays:
Days 1 - 4: $25 copay per day
Days 5 - 90: $0 copay per day
$0 copay for additional hospital days
$3 250 out-of-pocket limit every year.
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
Inpatient Mental Health CareYou get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
For Medicare-covered hospital stays:
Days 1 - 4: $25 copay per day
Days 5 - 90: $0 copay per day
$3 250 out-of-pocket limit every year.
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
Skilled Nursing Facility (SNF)Authorization rules may apply.
Plan covers up to 100 days each benefit period
No prior hospital stay is required.
For Medicare-covered SNF stays:
Days 1 - 4: $25 copay per day
Days 5 - 100: $0 copay per day
Home Health CareAuthorization rules may apply.
$0 copay for Medicare-covered home health visits
HospiceYou must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice.
Doctor Office Visits$0 copay for each primary care doctor visit for Medicare-covered benefits.
$0 copay for the cost of each in-area network urgent care Medicare-covered visit.
$15 copay for each specialist visit for Medicare-covered benefits.
Chiropractic ServicesAuthorization rules may apply.
$10 copay for each Medicare-covered visit
$15 copay for up to 10 supplemental routine visit(s) every year
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.
Podiatry ServicesAuthorization rules may apply.
$15 copay for each Medicare-covered visit
$15 copay for up to 3 supplemental routine visit(s) every year
Medicare-covered podiatry benefits are for medically-necessary foot care.
Outpatient Mental Health CareAuthorization rules may apply.
$10 copay for each Medicare-covered individual therapy visit
$10 copay for each Medicare-covered group therapy visit
$10 copay for each Medicare-covered individual therapy visit with a psychiatrist
$10 copay for each Medicare-covered group therapy visit with a psychiatrist
$15 copay for Medicare-covered partial hospitalization program services
Outpatient Substance Abuse CareAuthorization rules may apply.
$10 copay for Medicare-covered individual visits
$10 copay for Medicare-covered group visits
Outpatient Services/SurgeryAuthorization rules may apply.
$25 copay for each Medicare-covered ambulatory surgical center visit
$25 copay for each Medicare-covered outpatient hospital facility visit
Ambulance ServicesAuthorization rules may apply.
$0 copay for Medicare-covered ambulance benefits.
Emergency Care$50 copay for Medicare-covered emergency room visits
Worldwide coverage.
If you are admitted to the hospital within 1-day for the same condition you pay $0 for the emergency room visit.
Urgently Needed Care$0 copay for Medicare-covered urgently-needed-care visits
Outpatient Rehabilitation ServicesAuthorization rules may apply.
$4 copay for Medicare-covered Occupational Therapy visits
$4 copay for Medicare-covered Physical and/or Speech and Language Therapy visits
Durable Medical EquipmentAuthorization rules may apply.
0% to 20% of the cost for Medicare-covered items
Prosthetic DevicesAuthorization rules may apply.
0% to 20% of the cost for Medicare-covered items
Diabetes Programs and SuppliesAuthorization rules may apply.
$0 copay for Diabetes self-management training
0% to 20% of the cost for Diabetes monitoring supplies
0% to 20% of the cost for Therapeutic shoes or inserts
Diagnostic Tests X-Rays Lab Services and Radiology ServicesAuthorization rules may apply.
0% to 10% of the cost for Medicare-covered lab services
$0 copay for Medicare-covered diagnostic procedures and tests
$0 copay for Medicare-covered X-rays
$0 to $40 copay for Medicare-covered diagnostic radiology services (not including X-rays)
$0 copay for Medicare-covered therapeutic radiology services
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $0 to $15 may apply
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $0 to $15 may apply
Cardiac and Pulmonary Rehabilitation ServicesAuthorization rules may apply.
$10 copay for Medicare-covered Cardiac Rehabilitation Services
$10 copay for Medicare-covered Intensive Cardiac Rehabilitation Services
$10 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services and Wellness/Education Programs$0 copay for all preventive services covered under Original Medicare at zero cost sharing:
  • Abdominal Aortic Aneurysm screening
  • Bone Mass Measurement
  • Cardiovascular Screening
  • Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam)
  • Colorectal Cancer Screening
  • Diabetes Screening
  • Influenza Vaccine
  • Hepatitis B Vaccine
  • HIV Screening
  • Breast Cancer Screening (Mammogram)
  • Medical Nutrition Therapy Services
  • Personalized Prevention Plan Services (Annual Wellness Visits)
  • Pneumococcal Vaccine
  • Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only)
  • Smoking Cessation (Counseling to stop smoking)
  • Welcome to Medicare Physical Exam (Initial Preventive Physical Exam)
    • HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details.
    The plan covers the following supplemental education/wellness programs:
  • Written health education materials including Newsletters
  • Nutritional benefit
  • Additional Smoking Cessation
  • Nursing Hotline
    • Kidney Disease and ConditionsAuthorization rules may apply.
    $0 copay for renal dialysis
    $0 copay for kidney disease education services
    Outpatient Prescription Drugs$0 copay for Part B-covered drugs.
    This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.mmm-pr.com on the web.
    Different out-of-pocket costs may apply for people who
  • have limited incomes
  • live in long term care facilities or
  • have access to Indian/Tribal/Urban (Indian Health Service) providers.
    • The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
    Total yearly drug costs are the total drug costs paid by both you and a Part D plan.
    The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
    Some drugs have quantity limits.
    Your provider must get prior authorization from Medicare y Mucho Mas - ELITE (HMO-POS) for certain drugs.
    You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
    If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.
    If you request a formulary exception for a drug and Medicare y Mucho Mas - ELITE (HMO-POS) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug.
    $0 deductible.
    You pay the following until total yearly drug costs reach $2 930:
    Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (30-day) supply of drugs in this tier
  • $29 copay for a one-month (30-day) supply of drugs in this tier
  • $50 copay for a one-month (30-day) supply of drugs in this tier
  • 25% coinsurance for a one-month (30-day) supply of drugs in this tier
  • $15 copay for a three-month (90-day) supply of drugs in this tier
  • $87 copay for a three-month (90-day) supply of drugs in this tier
  • $150 copay for a three-month (90-day) supply of drugs in this tier
  • 25% coinsurance for a three-month (90-day) supply of drugs in this tier
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (31-day) supply of drugs in this tier
  • $29 copay for a one-month (31-day) supply of drugs in this tier
  • $50 copay for a one-month (31-day) supply of drugs in this tier
  • 25% coinsurance for a one-month (31-day) supply of drugs in this tier
    • Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $10 copay for a three-month (90-day) supply of drugs in this tier
  • $58 copay for a three-month (90-day) supply of drugs in this tier
  • $100 copay for a three-month (90-day) supply of drugs in this tier
  • 25% coinsurance for a three-month (90-day) supply of drugs in this tier
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    The plan covers many formulary generics (65%-99% of formulary generic drugs) through the coverage gap.
    You pay the following:
    Tier 1: Preferred Generic Drugs
  • $5 copay for a one-month (30-day) supply of select drugs covered in this tier
  • $15 copay for a three-month (90-day) supply of select drugs covered in this tier
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Tier 1: Preferred Generic Drugs
  • $5 copay for a one-month (31-day) supply of select drugs covered in this tier
    • Tier 1: Preferred Generic Drugs
  • $10 copay for a three-month (90-day) supply of select drugs covered in this tier
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    After your total yearly drug costs reach $2 930 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 86% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 700.
    Please contact the plan for a complete list of drugs covered through the gap.
    After your yearly out-of-pocket drug costs reach $4 700 you pay the greater of:
  • 5% coinsurance or
  • $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs.
    • Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Medicare y Mucho Mas - ELITE (HMO-POS).
    You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 930:
    Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (30-day) supply of drugs in this tier
  • $29 copay for a one-month (30-day) supply of drugs in this tier
  • $50 copay for a one-month (30-day) supply of drugs in this tier
  • 25% coinsurance for a one-month (30-day) supply of drugs in this tier
    • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    You will be reimbursed for these drugs purchased out-of-network up to the plan's cost of the drug minus the following:
    Tier 1: Preferred Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $5 copay for a one-month (30-day) supply of select drugs covered in this tier
  • You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700.
  • You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700.
  • You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700.
    • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share which is the greater of:
  • 5% coinsurance or
  • $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs.
    • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    Dental ServicesAuthorization rules may apply.
    50% of the cost for Medicare-covered dental benefits
    $5 copay for an office visit that includes:
  • up to 1 oral exam(s) every six months
  • up to 1 cleaning(s) every six months
  • up to 1 fluoride treatment(s) every six months
  • up to 1 dental x-ray(s) every three years
    • Plan offers additional comprehensive dental benefits.
    Hearing ServicesAuthorization rules may apply.
    $0 copay for hearing aids.
  • $10 copay for Medicare-covered diagnostic hearing exams
  • $0 copay for up to 1 supplemental routine hearing exam(s) every year
  • $0 copay for up to 1 hearing aid fitting-evaluation(s) every year
    • $200 plan coverage limit for hearing aids every three years.
    Vision Services$0 copay for
  • one pair of eyeglasses or contact lenses after cataract surgery
  • glasses
  • contacts
  • lenses
  • frames
  • $0 to $15 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $0 copay for up to 1 supplemental routine eye exam(s) every year
    • $225 plan coverage limit for eye wear every two years.
    Plan offers additional vision benefits. Contact plan for details.
    Over-the-Counter ItemsThe plan does not cover Over-the-Counter items.
    TransportationAuthorization rules may apply.
    $0 copay for up to 8 one-way trip(s) to any location every year
    AcupunctureAuthorization rules may apply.
    $15 copay per visit up to 10 visit(s).
    Point of ServiceAuthorization rules may apply.
    Point of Service coverage is available for the following benefits:
  • Inpatient Hospital Acute
  • Inpatient Hospital Psychiatric
  • Skilled Nursing Facility (SNF)
  • Cardiac Rehabilitation Services
  • Intensive Cardiac Rehabilitation Services
  • Pulmonary Rehabilitation Services
  • Partial Hospitalization
  • Home Health Services
  • Primary Care Physician Services
  • Chiropractic Services
  • Occupational Therapy Services
  • Physician Specialist Services
  • Mental Health Specialty Services
  • Podiatry Services
  • Other Health Care Professional
  • Psychiatric Services
  • Physical Therapy and Speech-Language Pathology Services
  • Outpatient Diagnostic Procedures/Tests/Lab Services
  • Diagnostic Radiological Services
  • Therapeutic Radiological Services
  • Outpatient X-Rays
  • Outpatient Hospital Services
  • Ambulatory Surgical Center (ASC) Services
  • Outpatient Substance Abuse
  • Outpatient Blood Services
  • Ambulance Services
  • Transportation Services
  • Durable Medical Equipment (DME)
  • Prosthetics/Medical Supplies
  • Diabetic Supplies and Services
  • Acupuncture
  • Medicare-covered Zero Cost-Sharing Preventive Services
  • Supplemental Education/Wellness Programs
  • Kidney Disease Education Services
  • Diabetes Self-Management Training
  • Preventive Dental
  • Comprehensive Dental
  • Eye Exams
  • Eye Wear
  • Hearing Exams
  • Hearing Aids
    • $10 000 plan coverage limit every year for the following POS Benefits:
  • Inpatient Hospital Acute
  • Inpatient Hospital Psychiatric
  • Skilled Nursing Facility (SNF)
  • Cardiac Rehabilitation Services
  • Intensive Cardiac Rehabilitation Services
  • Pulmonary Rehabilitation Services
  • Partial Hospitalization
  • Home Health Services
  • Primary Care Physician Services
  • Chiropractic Services
  • Occupational Therapy Services
  • Physician Specialist Services
  • Mental Health Specialty Services
  • Podiatry Services
  • Other Health Care Professional
  • Psychiatric Services
  • Physical Therapy and Speech-Language Pathology Services
  • Outpatient Diagnostic Procedures/Tests/Lab Services
  • Diagnostic Radiological Services
  • Therapeutic Radiological Services
  • Outpatient X-Rays
  • Outpatient Hospital Services
  • Ambulatory Surgical Center (ASC) Services
  • Outpatient Substance Abuse
  • Outpatient Blood Services
  • Ambulance Services
  • Transportation Services
  • Durable Medical Equipment (DME)
  • Prosthetics/Medical Supplies
  • Diabetic Supplies and Services
  • Acupuncture
  • Medicare-covered Zero Cost-Sharing Preventive Services
  • Supplemental Education/Wellness Programs
  • Kidney Disease Education Services
  • Diabetes Self-Management Training
  • Preventive Dental
  • Comprehensive Dental
  • Eye Exams
  • Eye Wear
  • Hearing Exams
  • Hearing Aids
    • 20% of the cost per hospital stay.
    20% of the cost per Inpatient Psychiatric Hospital stay.
    20% of the cost for each SNF stay.
    20% of the cost for
  • Cardiac Rehabilitation Services
  • Intensive Cardiac Rehabilitation Services
  • Pulmonary Rehabilitation Services
  • Partial Hospitalization
  • Home Health Services
  • Primary Care Physician Services
  • Chiropractic Services
  • Occupational Therapy Services
  • Physician Specialist Services
  • Mental Health Specialty Services
  • Podiatry Services
  • Other Health Care Professional
  • Psychiatric Services
  • Physical Therapy and Speech-Language Pathology Services
  • Outpatient Diagnostic Procedures/Tests/Lab Services
  • Diagnostic Radiological Services
  • Therapeutic Radiological Services
  • Outpatient X-Rays
  • Outpatient Hospital Services
  • Ambulatory Surgical Center (ASC) Services
  • Outpatient Substance Abuse
  • Outpatient Blood Services
  • Ambulance Services
  • Transportation Services
  • Durable Medical Equipment (DME)
  • Prosthetics/Medical Supplies
  • Diabetic Supplies and Services
  • Acupuncture
  • Medicare-covered Zero Cost-Sharing Preventive Services
  • Supplemental Education/Wellness Programs
  • Kidney Disease Education Services
  • Diabetes Self-Management Training
  • Preventive Dental
  • Comprehensive Dental
  • Eye Exams
  • Eye Wear
  • Hearing Exams
  • Hearing Aids
    • Premium and Other Important InformationIn 2012 the monthly Part B Standard Premium is $99.90 and the annual Part B deductible amount is $140.
    If a doctor or supplier does not accept assignment their costs are often higher which means you pay more.
    Most people will pay the standard monthly Part B premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
    Doctor and Hospital ChoiceYou may go to any doctor specialist or hospital that accepts Medicare.
    Inpatient Hospital CareIn 2012 the amounts for each benefit period are:
    Days 1 - 60: $1 156 deductible
    Days 61 - 90: $289 per day
    Days 91 - 150: $578 per lifetime reserve day
    Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days.
    Lifetime reserve days can only be used once.
    "A ""benefit period"" starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have."
    Inpatient Mental Health CareIn 2012 the amounts for each benefit period are:
    Days 1 - 60: $1 156 deductible
    Days 61 - 90: $289 per day
    Days 91 - 150: $578 per lifetime reserve day
    You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
    Skilled Nursing Facility (SNF)In 2012 the amounts for each benefit period after at least a 3-day covered hospital stay are:
    Days 1 - 20: $0 per day
    Days 21 - 100: $144.50 per day
    100 days for each benefit period.
    "A ""benefit period"" starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have."
    Home Health Care$0 copay.
    HospiceYou pay part of the cost for outpatient drugs and inpatient respite care.
    You must get care from a Medicare-certified hospice.
    Doctor Office Visits20% coinsurance
    Chiropractic ServicesSupplemental routine care not covered
    20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.
    Podiatry ServicesSupplemental routine care not covered.
    20% coinsurance for medically necessary foot care including care for medical conditions affecting the lower limbs.
    Outpatient Mental Health Care40% coinsurance for most outpatient mental health services
    Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible.
    """Partial hospitalization program"" is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization."
    Outpatient Substance Abuse Care20% coinsurance
    Outpatient Services/Surgery20% coinsurance for the doctor's services
    Specified copayment for outpatient hospital facility services Copay cannot exceed the Part A inpatient hospital deductible.
    20% coinsurance for ambulatory surgical center facility services
    Ambulance Services20% coinsurance
    Emergency Care20% coinsurance for the doctor's services
    Specified copayment for outpatient hospital facility emergency services.
    Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital.
    You don't have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit.
    Not covered outside the U.S. except under limited circumstances.
    Urgently Needed Care20% coinsurance or a set copay
    NOT covered outside the U.S. except under limited circumstances.
    Outpatient Rehabilitation Services20% coinsurance
    Durable Medical Equipment20% coinsurance
    Prosthetic Devices20% coinsurance
    Diabetes Programs and Supplies20% coinsurance for diabetes self-management training
    20% coinsurance for diabetes supplies
    20% coinsurance for diabetic therapeutic shoes or inserts
    Diagnostic Tests X-Rays Lab Services and Radiology Services20% coinsurance for diagnostic tests and x-rays
    $0 copay for Medicare-covered lab services
    Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests like checking your cholesterol.
    Cardiac and Pulmonary Rehabilitation Services20% coinsurance Cardiac Rehabilitation services 20% coinsurance for Pulmonary Rehabilitation services 20% coinsurance for Intensive Cardiac Rehabilitation services
    This applies to program services provided in a doctor+s office. Specified cost sharing for program services provided by hospital outpatient departments.
    Preventive Services and Wellness/Education ProgramsNo coinsurance copayment or deductible for the following:
  • Abdominal Aortic Aneurysm Screening
  • Bone Mass Measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions.
  • Cardiovascular Screening
  • Cervical and Vaginal Cancer Screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk.
  • Colorectal Cancer Screening
  • Diabetes Screening
  • Influenza Vaccine
  • Hepatitis B Vaccine for people with Medicare who are at risk
  • HIV Screening. $0 copay for the HIV screening but you generally pay 20% of the Medicare-approved amount for the doctor+s visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.
  • Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35-39.
  • Medical Nutrition Therapy Services Nutrition therapy is for people who have diabetes or kidney disease (but aren+t on dialysis or haven+t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease
  • Personalized Prevention Plan Services (Annual Wellness Visits)
  • Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information.
  • Prostate Cancer Screening + Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age 50.
  • Smoking Cessation (counseling to stop smoking). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits.
  • Welcome to Medicare Physical Exam (initial preventive physical exam) When you join Medicare Part B then you are eligible as follows. During the first 12 months of your new Part B coverage you can get either a Welcome to Medicare Physical Exam or an Annual Wellness Visit. After your first 12 months you can get one Annual Wellness Visit every 12 months.
    • Kidney Disease and Conditions20% coinsurance for renal dialysis
    20% coinsurance for kidney disease education services
    Outpatient Prescription DrugsMost drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan or you can get all your Medicare coverage including prescription drug coverage by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage.
    Dental ServicesPreventive dental services (such as cleaning) not covered.
    Hearing ServicesSupplemental routine hearing exams and hearing aids not covered.
    20% coinsurance for diagnostic hearing exams.
    Vision Services20% coinsurance for diagnosis and treatment of diseases and conditions of the eye.
    Supplemental routine eye exams and glasses not covered.
    Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery.
    Annual glaucoma screenings covered for people at risk.
    Over-the-Counter ItemsNot covered.
    TransportationNot covered.
    AcupunctureNot covered.
    Point of ServiceYou may go to any doctor specialist or hospital that accepts Medicare.
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    Help is available. If you have limited income and resources, you may qualify for help paying your Medicare health care and/or prescription drug coverage costs. For more information, visit socialsecurity.gov, call Social Security at 1-800-772-1213, or apply for help at your State Medical Assistance (Medicaid) office.

    If you have questions about Medicare, visit medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.