Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) There is no coinsurance, If you use tobacco, but do not have signs or symptoms of copayment, or deductible tobacco-related disease: We cover two counseling quit attempts for the Medicare-covered within a 12-month period as a preventive service with no cost to smoking and tobacco use you. Each counseling attempt includes up to four face-to-face cessation preventive visits. benefits. If you use tobacco and have been diagnosed with a disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12-month period, however, you will pay the applicable cost-sharing. Each counseling attempt includes up to four face-to-face visits. ____________________________________________________ ______________________ Transportation (Non-Emergent, Routine) $0 copay for up to 36 one- way trip(s) to plan Routine transportation services are covered for up to thirty-six approved locations every (36) one-way trips per calendar area within the Service Plan’s year Area. Please call Member Services for more details on how to use this service. Prior authorization may be required Routine Transportation is a trip to a scheduled medical appointment within a defined service when the need for transport is not based on medical necessity and can be met through a van, sedan or other non-ambulance vehicle. Trip must be arranged through the contracted transportation vendor and must be scheduled 3 days in advance of needed services. Urgently needed services Urgently needed services are provided to treat a non-emergency, 20% of the cost for unforeseen medical illness, injury, or condition that requires Medicare covered services immediate medical care. Urgently needed services may be (up to $65) furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. Cost sharing for necessary urgently needed services furnished out-of-network is the same as for such services furnished Urgent care is covered within the United States and its territories but not worldwide.
Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco-related disease: We cover two counseling quit attempts within a 12-month period as a preventive service with no cost to you. Each counseling attempt includes up to four face-to-face visits. If you use tobacco and have been diagnosed with a disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12-month period, however, you will pay the applicable cost-sharing. Each counseling attempt includes up to four face-to-face visits. ____________________________________________________ Transportation (Non-Emergent, Routine) Routine transportation services are covered for up to thirty-six (36) one-way trips per calendar area within the Plan’s Service Area. Please call Member Services for more details on how to use this service. Routine Transportation is a trip to a scheduled medical appointment within a defined service when the need for transport is not based on medical necessity and can be met through a van, sedan or other non-ambulance vehicle. Trip must be arranged through the contracted transportation vendor and must be scheduled 3 days in advance of needed services. There is no coinsurance, copayment, or deductible for the Medicare-covered smoking and tobacco use cessation preventive benefits. ______________________ $0 copay for up to 36 one- way trip(s) to plan approved locations every year Prior authorization may be required Urgently needed services Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. Cost sharing for necessary urgently needed services furnished out-of-network is the same as for such services furnished Urgent care is covered within the United States and its territories but not worldwide. 20% of the cost for Medicare covered services (up to $65)
H4093_ISNP_HMO_NONPOS_Model_wRx_v2-PA_EOC.docx