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In -Network <br />Vision Services Medicare -Covered Vision <br />Services <br />■ $45 copay for specialist to <br />diagnose and treat eye diseases <br />and conditions <br />• $0 copay for glaucoma screening <br />(once per year for members at <br />high risk of glaucoma) <br />■ $0 copay for one diabetic retinal <br />exam per year <br />■ $0 copay for one pair of <br />eyeglasses or contact lenses after <br />each cataract surgery <br />Additional Vision Services <br />In -Network <br />■ $0 copay for an annual routine <br />eye examination. <br />■ $0 copay for lenses, frames or <br />contacts. Subject to the annual <br />maximum plan benefit <br />allowance. Member responsible <br />for any amounts in excess of the <br />annual maximum plan benefit <br />allowance. <br />■ $250 maximum allowance per <br />year towards the purchase of <br />lenses, frames or contacts. <br />Mental Health <br />Inpatient Mental Health Services <br />Services 0 <br />. $200 copay per day for days 1-7 <br />(Authorization <br />■ $0 copay per day for days 8-90 <br />applies to in- <br />190 -day lifetime benefit maximum in <br />network <br />a psychiatric hospital. <br />services only) <br />Out -of -Network <br />Medicare -Covered Vision <br />Services <br />■ 40% of the Medicare -allowed amount for <br />glaucoma screening <br />■ 40% of the Medicare -allowed amount <br />after $2,000 out -of -network deductible <br />for Medicare -covered specialist services <br />to diagnose and treat diseases and <br />conditions of the eye <br />and diabetic retinal exams <br />40% of the Medicare -allowed amount <br />after $2,000 out -of -network deductible <br />for eyeglasses or contact lenses after <br />cataract surgery <br />Additional Vision Services <br />Out -of -Network <br />• Member must pay 100% of the charges <br />and submit the itemized receipt(s) for <br />reimbursement of 50% of the in -network <br />allowed amount for an annual routine <br />eye examination. <br />• Member must pay 100% of the charges <br />and submit the itemized receipt(s) for <br />reimbursement of 50% of the in -network <br />allowed amount for lenses, frames, or <br />contacts. <br />■ Member is responsible for all amounts <br />in excess of the 50% in -network allowed <br />amount and/or any amounts in excess <br />of the annual maximum plan benefit <br />allowance for lenses, frames or <br />contacts. <br />■ Total reimbursement is subject to the <br />annual maximum plan benefit <br />allowance. <br />Inpatient Mental Health Services <br />• 40% of the Medicare -allowed amount <br />after $2,000 out -of -network deductible <br />190 -day lifetime benefit maximum in a <br />psychiatric hospital. <br />9 335 <br />