Medical Benefits and Costs
PHP (HMO SNP) covers the medical services listed below at the specified cost sharing. For more details about the coverage and costs for these services, see Chapter 4, Medical Benefits Chart (what is covered and what you pay), in your 2025 Evidence of Coverage.
Benefit | Your Cost Sharing |
Acupuncture | You pay $0 copay for up to two acupuncture visits per month. |
Acupuncture for Chronic Low Back Pain | You pay $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:
An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. Treatment must be discontinued if the patient is not improving or is regressing. |
Ambulance Services | You pay $150 copay for one-way or round trips. |
Cardiac and Pulmonary Rehabilitation Services | You pay $0 copay per service. |
Chiropractic Care | You pay $0 copay per visit for Medicare-covered chiropractic services. The plan covers only manual manipulation of the spine to correct subluxation. |
Dental Services | Limited dental services (this does not include services in connection with care, treatment, filling removal or replacement of teeth): You pay $0 copay. Preventive dental services:
Comprehensive dental services such as the following: You pay $0 copay.
Comprehensive dental services are limited to $1,200 every year. |
Diabetes Self-Management Training, Diabetic Services and Supplies | You pay $0 copay for diabetes self-management training and diabetic services and supplies. |
Durable Medical Equipment and Related Supplies | You pay $0 copay per covered item Your cost sharing for Medicare oxygen equipment coverage is $0. If prior to enrolling in PHP you had made 36 months of rental payment for oxygen equipment coverage, your cost sharing in PHP is $0 |
Emergency Care | You pay $100 copay per emergency room visit. |
Fitness Benefit | You pay $0 copay for one gym membership Members receive a gym membership at one of the following gyms:
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Hearing Services | You pay $0 copay for a routine hearing exam every year. $2,500 plan coverage limit for up to 2 hearing aids every year. |
Home and bathroom safety devices and modifications | You pay $0 copay for covered home and bathroom safety devices and modifications up to the $5,000 annual limit. |
Home Health Agency Care | You pay $0 copay for covered home health visits and services. |
Home Infusion Therapy | You pay $0 copay for covered home infusion therapy services. |
Hospice Care | When enrolled in a Medicare-certified hospice program, your hospice and Part A and B services related to your terminal prognosis are paid for by Original Medicare. You pay $0 copay for hospice consultation services. |
In-Home Support Services (IHSS) | You pay $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. |
Inpatient Care |
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Inpatient Services in a Psychiatric Hospital |
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Meal Benefit | You pay $0 copay for up to two (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. |
Medicare Part B Prescription Drugs | You pay $0 copay per Medicare Part B prescription drug. Insulin cost sharing is limited to $35 for one-month’s supply. |
Non-Emergency Transportation | You pay $0 copay for up to 24 round trips to plan-approved locations every year. |
Opioid Treatment Program Services | You pay $0 copay for covered opioid treatment program services. |
Outpatient Diagnostic Tests and Therapeutic Services and Supplies |
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Outpatient Hospital Observation | You pay $0 copay for outpatient hospital observation. |
Outpatient Hospital Services | You pay $0 copay per visit/service. |
Outpatient Mental Health Care | You pay $0 copay per visit. |
Outpatient Rehabilitation Services | You pay $0 copay per visit for occupational, physical and speech language therapies. |
Outpatient Substance Abuse Services | You pay $0 copay per visit. |
Outpatient Surgery | You pay $0 copay per visit. |
Over-the-Counter (OTC) Pharmacy Items | $0 copay for over-the-counter pharmacy items. The OTC benefit is limited to $550 every year. |
Partial Hospitalization Services | You pay $0 copay per visit. |
Physician/Practitioner Services | You pay $0 copay per visit to primary care and specialist providers. |
Podiatry Services | You pay $0 copay per visit for Medicare-covered podiatry services. |
Preventive Services | You pay $0 copay for the following services:
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Prosthetic Devices and Related Supplies | You pay $0 copay for prosthetic devices and medical supplies. |
Pulmonary Rehabilitation Services | You pay $0 copay per service. |
Services to Treat Kidney Disease and Conditions | You pay $0 copay for kidney disease education services. You pay $0 copay per outpatient renal dialysis session. |
Skilled Nursing Facility (SNF) Care | You pay $0 copay per day for days 1 through 100. |
Special Supplemental Benefits for the Chronically Ill (SSBCI) | You pay $0 copay for up to two (2) therapeutic massages per month for members diagnosed with AIDS-related neuropathy. You pay $0 copay for up to two (2) diabetic meals per day for members who have been diagnosed with diabetes. You pay $0 copay for up to two (2) low-sodium meals per day for members who have been diagnosed with congestive heart failure (CHF). You pay $0 copay for pest control services. $1,000 plan coverage limit for pest control services every year for members who have been diagnosed with asthma or chronic pulmonary conditions and live in a residence that is infested with cockroaches, mice or rats. You pay $0 copay for air filter device(s) and filter replacements. $200 plan coverage limit for air filter device(s) and filter replacements every year for members who have been diagnosed with asthma or chronic pulmonary conditions and live in an environment whose air quality contributes to asthma and breathing problems. You pay $0 copay for laundry service. $156 plan coverage limit for laundry service every month for members who need daily living assistance and hygiene support and are unable to do their own laundry. |
Supervised Exercise Therapy (SET) | SET if covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. You pay $0 copay for up to 36 sessions over a 12-week period if the SET program requirements are met. |
Urgently Needed Services | You pay $0 copay per visit. |
Vision Services | You pay $0 copay per Medicare-covered vision care service. You pay $0 copay for routine annual eye exam. You pay $0 copay for glasses or contact lenses up to the $400 annual limit. Eye wear is limited to $400 ever year. |
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