| Plan Benefits | Leon MediMore (HMO) | ||
|---|---|---|---|
| Dental | |||
| Comprehensive Dental Maximum Benefit | $5,250 | ||
| Vision | |||
| Eyewear Lenses and Frames | $320 maximum benefit
(up to 2 pairs each year) | ||
| Hearing Services | |||
| Hearing Aids | $2,100 maximum benefit / 3 years ($1,050 per hearing aid, per ear) | ||
| Drugs/OTC | |||
| Maximum Annual Benefit | $200 annual | ||
| Leon Plus Card | |||
| Maximum Annual Benefit | not applicable | ||
| Part B Premium Give Back | |||
| Part B Premium Reduction | $167 per month | ||
| Acupuncture | |||
| Routine | $0 for up to 6 visits | ||
| Medical | |||
| PCP Visit | $0 | ||
| Inpatient Hospital (per admission) | Day(s) 1 – 5: $50 copay Days 6 – 90: $0 copay | ||
| Lab Services and X-Rays | $0 | ||
| Plan Benefits |
|---|
| Leon MediMore (HMO) |
| Dental |
| Comprehensive Dental Maximum Benefit |
| $5,250 |
| Vision |
| Eyewear Lenses and Frames |
| $320 maximum benefit
(up to 2 pairs each year) |
| Hearing Services |
| Hearing Aids |
| $2,100 maximum benefit / 3 years ($1,050 per hearing aid, per ear) |
| Drugs/OTC |
| Maximum Annual Benefit |
| $200 annual |
| Leon Plus Card |
| Maximum Annual Benefit |
| not applicable |
| Part B Premium Give Back |
| Part B Premium Reduction |
| $167 per month |
| Acupuncture |
| Routine |
| $0 for up to 6 visits |
| Medical |
| PCP Visit |
| $0 |
| Inpatient Hospital (per admission) |
| Day(s) 1 – 5: $50 copay Days 6 – 90: $0 copay |
| Lab Services and X-Rays |
| $0 |
