Medical Benefits and Costs
PHP (HMO SNP) covers the medical services listed below at the specified cost sharing. The information below describes these changes. 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 2023 Evidence of Coverage.
Your Cost Sharing
Ambulatory Surgery Center
You pay nothing for outpatient surgery and ambulatory surgery center services done at an ambulatory surgery center.
Referral and authorization required.
Cardiac and Pulmonary Rehabilitation Services
You pay nothing for cardiac and pulmonary rehabilitation services. Referral required. Certain cardiac and pulmonary rehabilitation procedures require authorization.
You pay nothing for Medicare-covered chiropractic services limited to manual manipulation of the spine to correct subluxation. Referral required. No authorization required.
You pay nothing for limited Medicare-covered dental services (this does not include services in connection with care, treatment, filling, removal or replacement of teeth). Referral and authorization required.
You pay nothing for preventive dental services:
You pay nothing for comprehensive dental services such as the following:
Comprehensive dental services are limited to $1,150 every year.
No referral or authorization required for preventive or comprehensive dental services.
You pay nothing for the following services:
Referral required. The following services require authorization:
The following services do not require authorization:
You pay nothing for the following services every year:
$2,500 plan coverage limit for up to 2 hearing aids every year.
Outpatient Hospital Observation
You pay nothing for outpatient hospital observation. No referral or authorization required.
Outpatient Hospital Services
You pay nothing for outpatient hospital services.
Some services require referral and authorization.
Outpatient Rehabilitation Services
You pay nothing for physical therapy, occupational therapy and speech language therapy. Referral required. No authorization required.
Outpatient Substance Abuse Services
You pay nothing for outpatient substance abuse services. Referral required. No authorization required.
Physician Specialist Services
You pay nothing for physician specialist visits. Referral required. Some specialist procedures require authorization.
You pay nothing for podiatry services. Referral required. Certain podiatric procedures require authorization.
You pay nothing for Medicare-covered vision care services. Referral and authorization required for the following:
Diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration
You pay nothing for supplemental vision care benefits. No referral or authorization required for the following:
$250 plan coverage limit for eyewear every year.