Summary of Benefits. This Summary of Benefits shows the amount you will pay for covered services under this Blue Shield of California plan. It is only a summary and it is part of the contract for health care coverage, called the Evi- dence of Coverage (EOC). Please read both documents carefully for details. Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE SERVICES YOU PAY INDEPENDENCE AND SAFE MOBILITY WITH AAA - Your benefit is provided by American Automobile Associ- ation of Northern California, Nevada & Utah (AAA). The benefit is a Classic AAA membership and includes access to Independent and Safe Mobility tools and services. Roadwise Driver Educational Driving Resources Roadside Assistance $0 FOREIGN TRAVEL – Medically necessary emergency care Services beginning during the first 60 days of each trip outside the United States. First $250 each Calendar Year $250 Remainder of charges 20% plus 100% of additional charges over the $50,000 lifetime maximum BASIC GYM ACCESS THROUGH SILVERSNEAKERS® FITNESS $0 Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE HEARING AID SERVICES – Your hearing aid services benefits are provided by EPIC Hearing Healthcare (EPIC®). This benefit is designed for you to use EPIC® network providers. EPIC® Participating providers may be located through a directory at xxxxxxxxxxxx.xxx/XxxxxxxXxx. If you choose to use out-of-network providers, those services will not be covered. This benefit is separate from diagnostic hearing examinations and related charges as covered by Medicare. Hearing aid examination for the appropriate type of hearing aid once every 12 months $0 Hearing aid benefits every 12 months include: Hearing aid instrument o Choice of the private-labeled Basic (mid-level) or Reserve (premium level) technology hearing aid models o Up to two hearing aids per 12 months in the following styles: in-the-ear; in-the-canal; completely-in-canal; behind-the-ear; or receiver-in-the-ear. o All technology levels include: one consultation; two-year supply of batteries per hearing aid; and three-year extended warranty. o Basic technology level hearing aids include: one behind-the-ear hearing aid delivered directly to your home; follow-up care is provided by EPIC online, telephoni- cally, or by video chat for no additional fee; and follow-up care in-person appointments are subject to an addi- tional fee per visit. o Reserve technology level hearing aids include: one hearing aid delivered in-person; up to three follow-up visits in-person for hearing aid fitting, con- sultation, device check, and adjustment within the first year for no additional fee; and ear impressions & molds. Basic Technology Level: $449 per aid plus $50 per visit for optional in-person appointments Reserve Technology Level: $699 per aid Plan G Inspire ADDITIONAL BENEFITS –NOT COVERED BY MEDICARE SERVICES YOU PAY In-Network Out-Of-Network VISION SERVICES – Your vision benefits are provided by Vision Service Plan (VSP). This benefit offers one of the largest na- tional network of independent doctors located in retail, neighborhood, medical and professional settings. You can lower any out of pocket costs by choosing network providers for covered services. VSP Participating Providers may be located through an online directory at xxxxxxxxxxxx.xxx. Click on Find a Doctor. Comprehensive eye exam once every 12 months $20 All costs above $50 Eyeglass frame once every 24 months All costs above $100 All costs above $40 Eyeglass lenses once every 12 months $25 Single vision: Single vision Bifocal Trifocal Aphakic or lenticular monofocal or multifocal All costs above $43 Bifocal:All costs above $60 Trifocal: All costs above $75 Aphakic or lenticular monofocal or multifocal: All costs above $104 Contact lenses (instead of eyeglass lenses) once every 12 months Non-elective (medically necessary) – Hard or Soft – one pair Non-elective (hard or soft):$25 copay Elective: $25 copay and all costs above $120 Non-elective (hard or soft): All costs above $200 Elective (cosmetic/convenience) – Hard – one pair Elective (cosmetic/convenience) – Soft – Up to a three- to six-month supply for each eye based on lenses selected Elective (hard or soft): All costs above $100 Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE SERVICES YOU PAY PHYSICIAN CONSULTATION BY PHONE OR VIDEO THROUGH TELADOC $0 per consult OVER-THE-COUNTER ITEMS THROUGH CVS – Eligible over-the-counter (OTC) items are available through the mail- order catalog, at xxxxxxxxxxxx.xxx/xxxxxxxxXXX. All costs above $100 one – time use per quarter allowance IMPORTANT! No person has the right to receive the benefits of this plan for Services furnished following termination of coverage except as specifically provided under the extension of benefits, Part I.B. of this Agreement. Benefits of this plan are available only for Services furnished during the term it is in effect and while the individual claiming benefits is actually covered by this Agreement. Benefits may be modified during the term of this plan as specifically provided under the terms of this Agreement or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or the elimination of benefits) apply to Services furnished on or after the effective date of the modification. There is no vested right to receive the benefits of this Agree- ment.
Appears in 1 contract
Summary of Benefits. This Summary of Benefits shows the amount you will pay for covered services under this Blue Shield of California plan. It is only a summary and it is part of the contract for health care coverage, called the Evi- dence of Coverage (EOC). Please read both documents carefully for details. Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE SERVICES YOU PAY INDEPENDENCE AND SAFE MOBILITY WITH AAA - Your benefit is provided by American Automobile Associ- ation of Northern California, Nevada & Utah (AAA). The benefit is a Classic AAA membership and includes access to Independent and Safe Mobility tools and services. • Roadwise Driver • Educational Driving Resources • Roadside Assistance $0 FOREIGN TRAVEL – Medically necessary emergency care Services beginning during the first 60 days of each trip outside the United States. First $250 each Calendar Year $250 Remainder of charges 20% plus 100% of additional charges over the $50,000 lifetime maximum BASIC GYM ACCESS THROUGH SILVERSNEAKERS® FITNESS $0 Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE HEARING AID SERVICES – Your hearing aid services benefits are provided by EPIC Hearing Healthcare (EPIC®). This benefit is designed for you to use EPIC® network providers. EPIC® Participating providers may be located through a directory at xxxxxxxxxxxx.xxx/XxxxxxxXxx. If you choose to use out-of-network providers, those services will not be covered. This benefit is separate from diagnostic hearing examinations and related charges as covered by Medicare. Hearing aid examination for the appropriate type of hearing aid once every 12 months $0 Hearing aid benefits every 12 months include: • Hearing aid instrument o Choice of the private-labeled Basic (mid-level) or Reserve (premium level) technology hearing aid models o Up to two hearing aids per 12 months in the following styles: ▪ in-the-ear; ▪ in-the-canal; ▪ completely-in-canal; ▪ behind-the-ear; or ▪ receiver-in-the-ear. o All technology levels include: ▪ one consultation; ▪ two-year supply of batteries per hearing aid; and ▪ three-year extended warranty. o Basic technology level hearing aids include: ▪ one behind-the-ear hearing aid delivered directly to your home; ▪ follow-up care is provided by EPIC online, telephoni- cally, or by video chat for no additional fee; and ▪ follow-up care in-person appointments are subject to an addi- tional fee per visit. o Reserve technology level hearing aids include: ▪ one hearing aid delivered in-person; ▪ up to three follow-up visits in-person for hearing aid fitting, con- sultation, device check, and adjustment within the first year for no additional fee; and ▪ ear impressions & molds. Basic Technology Level: $449 per aid plus $50 per visit for optional in-person appointments Reserve Technology Level: $699 per aid Plan G Inspire ADDITIONAL BENEFITS –NOT COVERED BY MEDICARE SERVICES YOU PAY In-Network Out-Of-Network VISION SERVICES – Your vision benefits are provided by Vision Service Plan (VSP). This benefit offers one of the largest na- tional network of independent doctors located in retail, neighborhood, medical and professional settings. You can lower any out of pocket costs by choosing network providers for covered services. VSP Participating Providers may be located through an online directory at xxxxxxxxxxxx.xxx. Click on Find a Doctor. Comprehensive eye exam once every 12 months $20 All costs above $50 Eyeglass frame once every 24 months All costs above $100 All costs above $40 Eyeglass lenses once every 12 months $25 Single vision: • Single vision Bifocal Trifocal vision• Bifocal• Trifocal• Aphakic or lenticular monofocal or multifocal All costs above $43 Bifocal:All costs above $60 Trifocal: All costs above $75 Aphakic or lenticular monofocal or multifocal: All costs above $104 Contact lenses (instead of eyeglass lenses) once every 12 months • Non-elective (medically necessary) – Hard or Soft – one pair Non-elective (hard or soft):$25 copay Elective: $25 copay and all costs above $120 Non-elective (hard or soft): All costs above $200 • Elective (cosmetic/convenience) – Hard – one pair • Elective (cosmetic/convenience) – Soft – Up to a three- to six-month supply for each eye based on lenses selected Elective (hard or soft): All costs above $100 Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE SERVICES YOU PAY PHYSICIAN CONSULTATION BY PHONE OR VIDEO THROUGH TELADOC $0 per consult OVER-THE-COUNTER ITEMS THROUGH CVS – Eligible over-the-counter (OTC) items are available through the mail- order catalog, at xxxxxxxxxxxx.xxx/xxxxxxxxXXX. All costs above $100 one – time use per quarter allowance IMPORTANT! No person has the right to receive the benefits of this plan for Services furnished following termination of coverage except as specifically provided under the extension of benefits, Part I.B. of this Agreement. Benefits of this plan are available only for Services furnished during the term it is in effect and while the individual claiming benefits is actually covered by this Agreement. Benefits may be modified during the term of this plan as specifically provided under the terms of this Agreement or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or the elimination of benefits) apply to Services furnished on or after the effective date of the modification. There is no vested right to receive the benefits of this Agree- ment.
Appears in 1 contract
Summary of Benefits. This Summary of Benefits shows the amount you will pay for covered services under this Blue Shield of California plan. It is only a summary and it is part of the contract for health care coverage, called the Evi- dence of Coverage (EOC). Please read both documents carefully for details. Plan G Inspire F Extra ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE SERVICES YOU PAY INDEPENDENCE AND SAFE MOBILITY WITH AAA - Your benefit is provided by American Automobile Associ- ation of Northern California, Nevada & Utah (AAA). The benefit is a Classic AAA membership and includes access to Independent and Safe Mobility tools and services. Roadwise Driver Educational Driving Resources Roadside Assistance $0 FOREIGN TRAVEL – Medically necessary emergency care Services beginning during the first 60 days of each trip outside the United States. First $250 each Calendar Year $250 Remainder of charges 20% plus 100% of additional charges over the $50,000 lifetime maximum BASIC GYM ACCESS THROUGH SILVERSNEAKERS® FITNESS $0 Plan G Inspire ADDITIONAL BENEFITS PERSONAL EMERGENCY REPSONSE SYSTEM (PERS) – NOT COVERED BY MEDICARE Your PERS benefits are provided by LifeStation®. • One personal emergency response system• Choice of an in-home system or mobile device with GPS/WiFi• Monthly monitoring• Necessary chargers and cords $0 HEARING AID SERVICES – Your hearing aid services benefits are provided by EPIC Hearing Healthcare (EPIC®). This benefit is designed for you to use EPIC® EPIC network providers. EPIC® EPIC Participating providers may be located through a directory Providers are listed at xxxxxxxxxxxx.xxx/XxxxxxxXxxxxxxxxxxxxxx.xxx/XxxxxxxXxxx. If you choose to use out-of-network providers, those services will not be covered. This benefit is separate from diagnostic hearing examinations and related charges as covered by MedicareMedi- care. Hearing aid examination for the appropriate type of hearing aid once every 12 months $0 Hearing aid benefits every 12 months year include: • One routine hearing exam • Hearing aid instrument o Choice of the private-labeled Basic Silver (mid-level) or Reserve Gold (premium level) technology tech- nology hearing aid models o Up to two hearing aids per 12 months in the following styles: in-the-ear; in-the-canal; completely-in-canal; behind-the-ear; or receiver-in-the-ear. o All technology levels include: one consultation; two-year supply of batteries per hearing aid; and three-year extended warranty. o Basic Silver technology level hearing aids include: one behind-the-ear hearing aid (non-ear mold model) delivered directly to your home; and up to three virtual follow-up care is provided visits by EPIC onlinea participating provider for hearing aid fitting, telephoni- callyconsultation, or by video chat device check, and adjustment for no additional fee; and follow-up care in-person appointments are subject to an addi- tional fee cost. $0 Silver Technology Level: $449 per visit. hearing aid Gold Technology Level: $699 per hearing aid o Reserve Gold technology level hearing aids include: one hearing aid delivered in-personperson by a participating provider; up to three in-person follow-up visits in-person for hearing aid fitting, con- sultation, device check, and adjustment within the first year for no additional feecost; and standard ear impressions molds & moldsimpressions. Basic Technology Level: $449 per aid plus $50 per visit for optional in-person appointments Reserve Technology Level: $699 per aid Plan G Inspire F Extra ADDITIONAL BENEFITS –– NOT COVERED BY MEDICARE SERVICES YOU PAY In-Network Out-Of-Network VISION SERVICES SERVICES– Your vision benefits are provided by Vision Service Plan (VSP). This benefit offers one of the largest na- tional national network of independent doctors located in retail, neighborhood, medical and professional settings. You can lower any out of out-of-pocket costs by choosing network providers for covered services. VSP Participating Providers may be located through an online directory at xxxxxxxxxxxx.xxx. Click on Find a Doctor. Comprehensive eye exam once every 12 months $20 All costs above $50 Eyeglass frame once every 24 months All costs above $100 All costs above $40 Eyeglass lenses once every 12 months $25 months• Single vision: Single vision Bifocal Trifocal vision• Bifocal• Trifocal• Aphakic or lenticular monofocal or multifocal $25 Single vision:All costs above $43 Bifocal:All costs above $60 Trifocal: All costs above $75 Aphakic or lenticular monofocal monofo- cal or multifocal: All costs above $104 Contact lenses (instead of eyeglass lenses) once every 12 months • Non-elective (medically necessary) – Hard or Soft – one pair Non-elective (hard or soft):$25 copay Elective: $25 copay and all costs above $120 Non-elective (hard or soft): All costs above $200 • Elective (cosmetic/convenience) – Hard – one pair • Elective (cosmetic/convenience) – Soft – Up to a three- to six-month supply for each eye based on lenses selected Non-elective (hard or soft): $25 copay and all costs above $500 Elective (hard or soft): $25 copay and all costs above $120 Non-elective (hard or soft): All costs above $200 Elective (hard or soft): All costs above $100 Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE SERVICES YOU PAY PHYSICIAN CONSULTATION BY PHONE OR VIDEO THROUGH TELADOC $0 per consult OVER-THE-COUNTER ITEMS THROUGH CVS – Eligible over-the-counter (OTC) items are available through the mail- order catalog, at xxxxxxxxxxxx.xxx/xxxxxxxxXXX. All costs above $100 one – time use per quarter allowance 120 IMPORTANT! No person has the right to receive the benefits of this plan for Services furnished following termination of coverage except as specifically provided under the extension of benefits, Part I.B. of this Agreement. Benefits of this plan are available only for Services furnished during the term it is in effect and while the individual claiming benefits is actually covered by this Agreement. Benefits may be modified during the term of this plan as specifically provided under the terms of this Agreement or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or the elimination of benefits) apply to Services furnished on or after the effective date of the modification. There is no vested right to receive the benefits of this Agree- ment.. I: CONDITIONS OF COVERAGE AND PAYMENT OF DUES A. ENROLLMENT
Appears in 1 contract
Summary of Benefits. This Summary of Benefits shows the amount you will pay for covered services under this Blue Shield of California plan. It is only a summary and it is part of the contract for health care coverage, called the Evi- dence of Coverage (EOC). Please read both documents carefully for details. Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE SERVICES YOU PAY INDEPENDENCE AND SAFE MOBILITY WITH AAA - Your benefit is provided by American Automobile Associ- ation of Northern California, Nevada & Utah (AAA). The benefit is a Classic AAA membership and includes access to Independent and Safe Mobility tools and services. • Roadwise Driver • Educational Driving Resources • Roadside Assistance $0 FOREIGN TRAVEL – Medically necessary emergency care Services beginning during the first 60 days of each trip outside the United States. First $250 each Calendar Year $250 Remainder of charges 20% plus 100% of additional charges over the $50,000 lifetime maximum BASIC GYM ACCESS THROUGH SILVERSNEAKERS® FITNESS $0 Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE HEARING AID SERVICES – Your hearing aid services benefits are provided by EPIC Hearing Healthcare (EPIC®). This benefit is designed for you to use EPIC® EPIC network providers. EPIC® EPIC Participating providers may be located through a directory Providers are listed at xxxxxxxxxxxx.xxx/XxxxxxxXxxxxxxxxxxxxxx.xxx/XxxxxxxXxxx. If you choose to use out-of-network providers, those services will not be covered. This benefit is separate from diagnostic hearing examinations and related charges as covered by MedicareMedi- care. Hearing aid examination for the appropriate type of hearing aid once every 12 months $0 Hearing aid benefits every 12 months year include: • One routine hearing exam • Hearing aid instrument o Choice of the private-labeled Basic Silver (mid-level) or Reserve Gold (premium level) technology tech- nology hearing aid models o Up to two hearing aids per 12 months in the following styles: ▪ in-the-ear; ▪ in-the-canal; ▪ completely-in-canal; ▪ behind-the-ear; or ▪ receiver-in-the-ear. o All technology levels include: ▪ one consultation; ▪ two-year supply of batteries per hearing aid; and ▪ three-year extended warranty. o Basic Silver technology level hearing aids include: ▪ one behind-the-ear hearing aid (non-ear mold model) delivered directly to your home; and $0 Silver Technology Level: $449 per hearing aid Gold Technology Level: $699 per hearing aid ▪ up to three virtual follow-up care is provided visits by EPIC onlinea participating provider for hearing aid fitting, telephoni- callyconsultation, or by video chat device check, and adjustment for no additional fee; and follow-up care in-person appointments are subject to an addi- tional fee per visitcost. o Reserve Gold technology level hearing aids include: ▪ one hearing aid delivered in-personperson by a participating provider; ▪ up to three in-person follow-up visits in-person for hearing aid fitting, con- sultation, device check, and adjustment within the first year for no additional feecost; and ▪ standard ear impressions molds & moldsimpressions. Basic Technology Level: $449 per aid plus $50 per visit for optional in-person appointments Reserve Technology Level: $699 per aid Plan G Inspire ADDITIONAL BENEFITS –– NOT COVERED BY MEDICARE SERVICES YOU PAY In-Network Out-Of-Network VISION SERVICES SERVICES– Your vision benefits are provided by Vision Service Plan (VSP). This benefit offers one of the largest na- tional national network of independent doctors located in retail, neighborhood, medical and professional settings. You can lower any out of out-of-pocket costs by choosing network providers for covered services. VSP Participating Providers may be located through an online directory at xxxxxxxxxxxx.xxx. Click on Find a Doctor. Comprehensive eye exam once every 12 months $20 All costs above $50 Eyeglass frame once every 24 months All costs above $100 All costs above $40 Eyeglass lenses once every 12 months $25 Single vision: • Single vision Bifocal Trifocal vision• Bifocal• Trifocal• Aphakic or lenticular monofocal or multifocal All costs above $43 Bifocal:All costs above $60 Trifocal: All costs above $75 Aphakic or lenticular monofocal monofo- cal or multifocal: All costs above $104 Contact lenses (instead of eyeglass lenses) once every 12 months • Non-elective (medically necessary) – Hard or Soft – one pair Non-elective (hard or soft):$25 copay Elective: $25 copay and all costs above $120 Non-elective (hard or soft): All costs above $200 • Elective (cosmetic/convenience) – Hard – one pair • Elective (cosmetic/convenience) – Soft – Up to a three- to six-month supply for each eye based on lenses selected Non-elective (hard or soft): $25 copay and all costs above $500 Elective (hard or soft): $25 copay and all costs above $120 Non-elective (hard or soft): All costs above $200 Elective (hard or soft): All costs above $100 Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE SERVICES YOU PAY PHYSICIAN CONSULTATION BY PHONE OR VIDEO THROUGH TELADOC $0 per consult OVER-THE-COUNTER ITEMS THROUGH CVS – Eligible over-the-counter (OTC) items are available through the mail- order catalogOTC Items Catalog, at xxxxxxxxxxxx.xxx/xxxxxxxxXXXxxx.xxxxxxxxxxxx.xxx/xxxxxxxxXXX. Limitations may apply. Refer to the OTC Items Catalog for more information. Up to two orders per quarter All costs above the $100 one – time use Allow- ance per quarter allowance IMPORTANT! No person has the right to receive the benefits of this plan for Services furnished following termination of coverage except as specifically provided under the extension of benefits, Part I.B. of this Agreement. Benefits of this plan are available only for Services furnished during the term it is in effect and while the individual claiming benefits is actually covered by this Agreement. Benefits may be modified during the term of this plan as specifically provided under the terms of this Agreement or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or the elimination of benefits) apply to Services furnished on or after the effective date of the modification. There is no vested right to receive the benefits of this Agree- ment.. I: CONDITIONS OF COVERAGE AND PAYMENT OF DUES A. ENROLLMENT
Appears in 1 contract
Summary of Benefits. This Summary of Benefits shows the amount you will pay for covered services under this Blue Shield of California plan. It is only a summary and it is part of the contract for health care coverage, called the Evi- dence of Coverage (EOC). Please read both documents carefully for details. Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE SERVICES YOU PAY INDEPENDENCE AND SAFE MOBILITY WITH AAA - Your benefit is provided by American Automobile Associ- ation Associa- tion of Northern California, Nevada & Utah (AAA). The benefit is a Classic AAA membership and includes access to Independent and Safe Mobility tools and services. • Roadwise Driver • Educational Driving Resources • Roadside Assistance $0 FOREIGN TRAVEL – Medically necessary emergency care Services beginning during the first 60 days of each trip outside the United States. First $250 each Calendar Year $250 Remainder of charges 20% plus 100% of additional charges over the $50,000 lifetime life- time maximum BASIC GYM ACCESS THROUGH SILVERSNEAKERS® FITNESS $0 Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE HEARING AID SERVICES – Your hearing aid services benefits are provided by EPIC Hearing Healthcare (EPIC®). This benefit is designed for you to use EPIC® EPIC network providers. EPIC® EPIC Participating providers may be located through a directory Providers are listed at xxxxxxxxxxxx.xxx/XxxxxxxXxxxxxxxxxxxxxx.xxx/XxxxxxxXxxx. If you choose to use out-of-network providers, those services will not be covered. This benefit is separate from diagnostic hearing examinations and related charges as covered by Medicare. Hearing aid examination for the appropriate type of hearing aid once every 12 months $0 Hearing aid benefits every 12 months year include: • One routine hearing exam • Hearing aid instrument o Choice of the private-labeled Basic Silver (mid-level) or Reserve Gold (premium level) technology hearing aid models o Up to two hearing aids per 12 months in the following styles: in-the-ear; in-the-canal; completely-in-canal; behind-the-ear; or receiver-in-the-ear. o All technology levels include: one consultation; two-year supply of batteries per hearing aid; and three-year extended warranty. o Basic Silver technology level hearing aids include: one behind-the-ear hearing aid (non-ear mold model) delivered directly to your home; and up to three virtual follow-up care is provided visits by EPIC onlinea participating provider for hearing aid fitting, telephoni- callyconsultation, or by video chat device check, and adjustment for no additional fee; and follow-up care in-person appointments are subject to an addi- tional fee per visitcost. o Reserve Gold technology level hearing aids include: one hearing aid delivered in-personperson by a participating provider; up to three in-person follow-up visits in-person for hearing aid fitting, con- sultationconsultation, device check, and adjustment within the first year for no additional feecost; and standard ear impressions molds & moldsimpressions. Basic $0 Silver Technology Level: $449 per hearing aid plus $50 per visit for optional in-person appointments Reserve Gold Technology Level: $699 per hearing aid Plan G Inspire ADDITIONAL BENEFITS –– NOT COVERED BY MEDICARE SERVICES YOU PAY In-Network Out-Of-Network VISION SERVICES SERVICES– Your vision benefits are provided by Vision Service Plan (VSP). This benefit offers one of the largest na- tional national network of independent doctors located in retail, neighborhood, medical and professional settings. You can lower any out of out-of-pocket costs by choosing network providers for covered services. VSP Participating Providers may be located through an online directory at xxxxxxxxxxxx.xxx. Click on Find a Doctor. Comprehensive eye exam once every 12 months $20 All costs above $50 Eyeglass frame once every 24 months All costs above $100 All costs above $40 Eyeglass lenses once every 12 months $25 months• Single vision: Single vision Bifocal Trifocal vision• Bifocal• Trifocal• Aphakic or lenticular monofocal or multifocal $25 Single vision:All costs above $43 Bifocal:All costs above $60 Trifocal: All costs above $75 Aphakic or lenticular monofocal or multifocal: All costs above $104 Contact lenses (instead of eyeglass lenses) once every 12 months months• Non-elective (medically necessary) – Hard or Soft – one pair Non-elective (hard or soft):$25 copay Elective: $25 copay and all costs above $120 Non-elective (hard or soft): All costs above $200 pair• Elective (cosmetic/convenience) – Hard – one pair • Elective (cosmetic/convenience) – Soft – Up to a three- to six-month supply for each eye based on lenses selected Non-elective (hard or soft): $25 copay and all costs above $500 Elective (hard or soft): $25 copay and all costs above $120 Non-elective (hard or soft): All costs above $200 Elective (hard or soft): All costs above $100 Plan G Inspire ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE SERVICES YOU PAY PHYSICIAN CONSULTATION BY PHONE OR VIDEO THROUGH TELADOC $0 per consult OVER-THE-COUNTER ITEMS THROUGH CVS – Eligible over-the-counter (OTC) items are available through the mail- order catalogOTC Items Catalog, at xxxxxxxxxxxx.xxx/xxxxxxxxXXXxxx.xxxxxxxxxxxx.xxx/xxxxxxxxXXX. Limitations may apply. Refer to the OTC Items Catalog for more information. Up to two orders per quarter All costs above the $100 one – time use Allowance per quarter allowance IMPORTANT! No person has the right to receive the benefits of this plan for Services furnished following termination of coverage except as specifically provided under the extension of benefits, Part I.B. of this Agreement. Benefits of this plan are available only for Services furnished during the term it is in effect and while the individual claiming benefits is actually covered by this Agreement. Benefits may be modified during the term of this plan as specifically provided under the terms of this Agreement or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or the elimination of benefits) apply to Services furnished on or after the effective date of the modification. There is no vested right to receive the benefits of this Agree- ment.. I: CONDITIONS OF COVERAGE AND PAYMENT OF DUES A. ENROLLMENT
Appears in 1 contract
