California PHP

                     Benefit

        Original Medicare

                        PHP

Acupuncture

Not covered.

$0 copay for Medicare-covered acupuncture services for chronic low back pain.

Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:

For the purpose of this benefit, chronic low back pain is defined as:

• Lasting 12 weeks or longer;

• nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory or infectious disease, etc.);

• not associated with surgery;  and

• not associated with pregnancy.

Dental Services

Preventive dental services (such as cleaning) not covered.

$0 copay for Medicare covered preventive dental services such as oral exams, cleanings, fluoride treatments and dental x-rays, and other dental services.

In addition to the preventive services above, plan covers up to $1,200 a year for comprehensive dental services such as non-routine, diagnostic, and restorative services; endodontics, periodontics, and extractions; and prosthodontics, oral and maxillofacial surgery, etc.

Health and Wellness

Supplemental health and wellness programs not covered.

The Health and Wellness Benefit is not covered. The gym membership and over-the-counter (OTC) pharmacy benefits are decoupled so you receive both a gym membership and OTC pharmacy benefits.

$0 copay for access to 24 hour nurse hotline.

Hearing Services

Supplemental routine hearing exams and hearing aids not covered.

$0 copay for a routine hearing exam every year.

$0 copay for up to 2 hearing aids every year including a fitting evaluation.

Plan covers up to $2,500 a year for hearing aids.

In-Home Support Services (IHSS)

Not covered.

$0 copay for up to 16 hours a week of IHSS for up to 2 weeks per year. IHSS include personal care and domestic services. IHSS are available to members after discharge from an acute hospital or skilled nursing facility.

Meal Benefit

Not covered.

$0 copay for up to 2 meals per day for up to 28 days. (56 meal limit per year.) Meal benefit is available to members post-inpatient discharge from an acute hospital or skilled nursing facility and members who have a chronic condition or other medical condition that prevents leaving the home to grocery shop. Meals may be provided in multiple increments through the year up to the 56-meal limit for the year.

Non-Emergency Transportation

Not covered.

$0 copay for 24 round trips to plan-approved locations every year.

Therapeutic Massage

Not covered.

$0 copay for up to 2 therapeutic massages per month for members diagnosed with AIDS-related neuropathy.

Vision Services

Supplemental routine eye exams and glasses not covered.

$0 copay for one routine eye exam every year.

$0 copay for glasses, lenses or contacts.

Plan covers up to $400 a year for eye wear.