Y0066_SB_H2001_817_000_2024_M. Summary of Benefits January 1, 2024 - December 31, 2024 This is a summary of what we cover and what you pay. Review the Evidence of Coverage (EOC) for ... HealthSelect Medicare Advantage Plan PPO Medical premium and limits In-network and out-of-network Monthly plan premium Contact your group plan benefit ...Copayment for Medicare Covered Physician Specialist Office Visit $65.00. Inpatient Hospital Care. In-Network: Acute Hospital Services: $275.00 per day for days 1 to 6. $0.00 per day for days 7 to 90. Prior Authorization Required for Acute Hospital Services. Prior authorization required. Out-of-Network:8 a.m.-8 p.m. local time, Monday - Friday ... Y0066_EOC_H2001_816_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1, 2023 - December 31, 2023 Evidence of Coverage Your Medicare Health Benefits and Services and Prescription Drug ... Medicare PPO is approved by Medicare and run by a private company.

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