Limitations, exceptions, & benefit information about benefits) [Plans should provide specific information about: need Services you may need [This for referrals, need for prior authorization, category includes examples of Your costs for utilization management restrictions for drugs, services that beneficiaries may need. in-network providers maximum out of pocket costs on services, and The health plan should add or delete [Plans should insert permissible OON services and applicable cost any services on the services cost sharing where sharing (if different than in-network cost Health need or problem covered by the State.] applicable.] sharing).] Visits to an injury or illness $0 You want to see a doctor Wellness visits, such as a physical $0 Transportation to a doctor’s office $0 Specialist care $0 Care to keep you from getting sick, $0 such as flu shots to Medicare” preventive $0 “Welcome visit (one time only) You need medical tests Lab tests, such as blood work $0 X-rays or pictures, such as $0 CAT scans Screening tests, such as tests to $0 check for cancer
Health need or problem Services you may need [This category includes examples of services that beneficiaries may need. The health plan should add or delete any services on the services covered by the State.] Your costs for in-network providers [Plans should insert cost sharing where applicable.] Limitations, exceptions, & benefit information about benefits) [Plans should provide specific information about: need for referrals, need for prior authorization, utilization management restrictions for drugs, maximum out of pocket costs on services, and permissible OON services and applicable cost sharing (if different than in-network cost sharing).] You want to see a doctor Visits to an injury or illness $0 Wellness visits, such as a physical $0 Transportation to a doctor’s office $0 Specialist care $0 Care to keep you from getting sick, such as flu shots $0 “Welcome to Medicare” preventive visit (one time only) $0 You need medical tests Lab tests, such as blood work $0 X-rays or pictures, such as CAT scans $0 Screening tests, such as tests to check for cancer $0
VASBEng.docx