Florida PHP

Your Cost Sharing

You pay $0 copay for up to 12 visits in 90 days 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 systematic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease;
• not associated with surgery; and
• not associated with pregnancy.

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.

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:

• Cleaning (for up to 2 every year): You pay $0 copay.
• Dental x-ray(s) (for up to 1 every year): You pay $0 copay.
• Fluoride treatment (for up to 2 every year): You pay $0 copay.
• Oral exam: You pay $0 copay.

Comprehensive dental services such as the following: You pay $0 copay.

• Non-routine services
• Diagnostic services
• Restorative services
• Endodontics/ periodontics/ extractions
• Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental services are limited to $850 every year.

You pay $0 copay for covered hearing services and hearing aids.

Hearing aids are limited to $1,000 every year.

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.

You pay $0 copay for up to 16 hours a week of IHSS for up to two (2) weeks. IHSS is available to members after inpatient discharge from an acute hospital or skilled nursing facility.

• You pay $100 copay per day for days 1 through 6.
• You pay $0 copay per day for days 7 through 90.
• You pay $0 copay per day for “lifetime reserve days” 91 through 150.

• You pay $100 copay per day for days 1 through 6.
• You pay $0 copay per day for days 7 through 90.
• You pay $0 copay per day for “lifetime reserve” days 91 through 150.

• You pay $0 copay for medical supplies.
• You pay $0 copay per laboratory test.
• You pay $0 copay per diagnostic test or procedure.
• You pay $0 copay per therapeutic radiology service.
• You pay $0 copay per X-ray service.
• You pay $0 copay per unit (pint) of blood.
• You pay $0 copay per diagnostic radiological service, i.e., CT, MRI, etc.

If diagnostic, lab or imaging services are done at a hospital facility, you will be subject to an outpatient hospital services copay. See “Outpatient hospital services” below.

You pay $0 copay for the following services:

• Abdominal aortic aneurysm screening
• Alcohol misuse counseling
• Annual wellness visit
• Bone mass measurements
• Breast cancer screening (mammograms)
• Cardiovascular disease risk reduction visit
• Cardiovascular disease screening
• Cervical and vaginal cancer screening
• Colorectal cancer screening
• Depression screening
• Diabetes screening
• HIV screening
• Immunizations, including Flu shots, Hepatitis B shots, Pneumococcal shots
• Lung cancer screening with low dose computed tomography
• Medical nutrition therapy
• Medicare Diabetes Prevention Program
• Obesity screening and therapy to promote sustained weight loss
• Prostate cancer screening exams
• Sexually transmitted infections screening and counseling
• Smoking and tobacco use cessation (counseling to stop smoking or tobacco use)
• “Welcome to Medicare” preventive visit (one-time)

• You pay $0 copay for kidney disease education services.
• You pay $0 copay per outpatient renal dialysis session.

• You pay $0 copay per day for days 1 through 20.
• You pay $100 copay per day for days 21 through 100.

• 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 $200 annual limit.

Eye wear is limited to $200 ever year.