Florida PHP

                      Benefit

                                              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.

Chiropractic Services

You pay nothing for Medicare-covered chiropractic services limited to manual manipulation of the spine to correct subluxation.  Referral required.  No authorization required.

Dental Services

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:

• Cleaning (for up to 2 every year)
• Dental x-ray(s) (for up to 1 every year)
• Fluoride treatment (for up to 2 every year)
• Oral exams (unlimited)

You pay nothing for comprehensive dental services such as the following:

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

Comprehensive dental services are limited to $1,150 every year.

No referral or authorization required for preventive or comprehensive dental services.

Diagnostic Services/
Labs/Imaging

You pay nothing for the following services:

• Diagnostic radiology services, e.g., MRI, CT, PET scans
• Lab services
• Diagnostic tests and procedures
• Outpatient x-rays
• Colonoscopy,
  sigmoidoscopy,
  endoscopy
• Radiation therapy

Referral required.  The following services require authorization:

• Certain diagnostic procedures and tests
• Certain diagnostic radiological services
• Certain therapeutic radiological services

The following services do not require authorization:

• Lab
• X-rays

Hearing Services

You pay nothing for the following services every year:

• One routine hearing exam
• One fitting-evaluation for a hearing aid
• Up to two hearing aids

$2,500 plan coverage limit for up to 2 hearing aids every year.

Authorization required

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.

Podiatry Services

You pay nothing for podiatry services.  Referral required.  Certain podiatric procedures require authorization.

Vision Care

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

• For members who at high risk for glaucoma, one glaucoma screening each year
• For members with diabetes, one diabetic retinopathy screening each year
• One (1) pair of eyeglasses or contact lenses after cataract surgery that includes insertion of an intraocular lens

You pay nothing for supplemental vision care benefits. No referral or authorization required for the following:

• One (1) routine eye exam every year
• One (1) pair of eyeglasses (lenses and frames or lenses) or contact lenses every year

$250 plan coverage limit for eyewear every year.