b'UnitedHealthcare Group Medicare Advantage PPOHumana Group Medicare HMOwith Express Scripts Medicare (PDP) for CTPF Medicarewith Part D Pharmacy Medicare Advantage planAdvantage planOUTPATIENT SERVICES OUTPATIENT SERVICESChemotherapy, Radiation100% after deductible Chemotherapy, Radiation$50 Copay outpatient hospital, $25 SpecialistEmergency Room $50 Emergency Room Lab/X-Ray100% after deductible $50 Copay emergency room; waived if admitted Speech, Physical & Occupational Therapy,within 24 hours; applies for care outside USOutpatient Rehab100% after deductible Lab/X-Ray100% covered except urgent care, $25 Copay urgent careSurgery100% after deductible Speech, Physical & Occupational Therapy, Urgent Care100% after deductible Outpatient RehabPROFESSIONAL & OTHER SERVICES 100% per visit after $25-$40 copayAmbulance100% after deductible (based on where services are rendered)Allergy Shots100% after deductible Surgery$100Copay per visit in hospitalChiropractic Visits100% after deductible (unlimited visits);$75Copay per visit in ambulatory surgical facilityMedicare covered servicesDental100% after deductible; Medicare covered services only Urgent Care $25CopayDiabetic Part B Covered Supplies100% covered PROFESSIONAL & OTHER SERVICESHearing Ambulance$50 Copay per date of serviceMedicare-covered Services: 100% after deductibleRoutine (Non-Medicare) Services: $0 copay routine Allergy ShotsNo copayhearing examHearing Aids: $1,000 allowance purchased in networkChiropractic Visits$20 Copay;through UnitedHealthcare Hearing every three years Medicare guidelines applyHome Health Services100% after deductible Dental$25 copay (Medicare covered services only)Physician Office Visits100% after deductible Diabetic Part B Covered Supplies100% coveredPreventive Care (physicals, diagnostics,Hearing$10 Copay at a primary care physician immunizations)100% covered(1 physical per plan year)$25 copay at a Specialist -Medicare coveredProsthetic Devices, Med. Equip100% after deductibleservices onlyPodiatryHome Health ServicesNo copay (prior authorization Medicare-covered Services100% after deductible required) excludes personal home careRoutine (Non-Medicare) Services100% after deductible,Physician Office Visits6 visits per year $10 Copay PCP,$25 Copay specialistRenal Dialysis100% after deductible Preventive Care (physicals, diagnostics, immunizations)No copayTransplants100% after deductible Prosthetic Devices, Med. Equip10% at medical Vision Servicesequipment provider or pharmacyMedicare covered Services: 100% after deductible;Podiatry$25 Copay; Medicare covered services onlyEye Wear: $0 copay Medicare covered standard eyeglassRenal DialysisNo copay in dialysis center; 20% at lenses and frames after cataract surgery.hospitalRoutine (Non-Medicare Covered) Services: $0 copay annualTransplantsAs any other disease at Medicare-routine eye exam; $300 eye wear allowance every two years. approved Humana National Transplant Network only Extra Benefits (wellness, discounts) $60/quarter over theVision Services$25 Copay; Medicare covered counter benefit, HouseCalls, Silver Sneakers, hearing aidservices only discount, virtual office visits, Renew Rewards and more.Extra Benefits (wellness, discounts)Contact carrier CTPF 2021 HEALTH INSURANCE HANDBOOKContact carrier for more benefit details. for extra benefit details. EALTH INSURANCE HANDBOOK CTPF 2021 H 41'