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Check eligible items and delivery rules.","source":"pbp_b13_other_services: pbp_b13b_maxplan_amt / pbp_b13b_otc_maxplan_per"},{"label":"Preventive dental maximum","amount":1200.0,"period":"Every year","note":"Check service limits; may share a limit with comprehensive dental.","source":"pbp_b16_dental: pbp_b16b_maxplan_pv_amt / pbp_b16b_maxplan_pv_per"},{"label":"Comprehensive dental maximum","amount":null,"period":"","note":"Shares the preventive dental limit; do not add the two amounts.","source":"pbp_b16_dental: pbp_b16c_maxplan_cmp_type"},{"label":"Combined eyewear maximum","amount":125.0,"period":"Every year","note":"Combined eyewear allowance; check covered items and provider rules.","source":"pbp_b17_eye_exams_wear: pbp_b17b_comb_maxplan_amt / pbp_b17b_comb_maxplan_per"},{"label":"Hearing-aid maximum","amount":2000.0,"period":"Every year","note":"Check whether the limit is per ear, device, or combined; network and device restrictions apply.","source":"pbp_b18_hearing_exams_aids: pbp_b18b_maxplan_amt / pbp_b18b_maxplan_per"},{"label":"Food / produce maximum (conditional SSBCI)","amount":0.0,"period":"Every month","note":"Only for members meeting the plan’s SSBCI criteria; Medicaid alone does not establish eligibility. May be shared with other benefits.","source":"pbp_b13i_b19b_services_vbid_ssbci: pbp_b13i_fd_maxplan_amt / pbp_b13i_fd_maxplan_per"},{"label":"Shared benefit: Combined OTC + Other Supplemental","amount":53.0,"period":"Every one month","note":"One combined limit, not an additional allowance. 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provide."},{"category":"Vision","service":"Other","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Vision","service":"Routine eye exam","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Vision","service":"Upgrades","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Wellness programs (e.g.; fitness, nursing hotline)","service":"","limit":null,"authorization":"No","referral":"No","network":"In-Network","cost":"Covered"}],"giveback":0,"allowances":[{"label":"Combined eyewear maximum","amount":350.0,"period":"Every year","note":"Combined eyewear allowance; check covered items and provider rules.","source":"pbp_b17_eye_exams_wear: pbp_b17b_comb_maxplan_amt / pbp_b17b_comb_maxplan_per"},{"label":"Hearing-aid maximum","amount":1300.0,"period":"Every three years","note":"Check whether the limit is per ear, device, or combined; network and device restrictions apply.","source":"pbp_b18_hearing_exams_aids: pbp_b18b_maxplan_amt / pbp_b18b_maxplan_per"},{"label":"Shared benefit: Combined OTC/ SSBCI/OTC Hearing Benefits","amount":200.0,"period":"Every one month","note":"One combined limit, not an additional allowance. Confirm which benefits and eligibility rules apply.","source":"pbp_Section_D: pbp_d_combo_max_plan_ben_amt_1 / pbp_d_combo_max_plan_period_1"},{"label":"Shared benefit: Flex Card","amount":375.0,"period":"Every year","note":"One combined limit, not an additional allowance. Confirm which benefits and eligibility rules apply.","source":"pbp_Section_D: pbp_d_combo_max_plan_ben_amt_3 / pbp_d_combo_max_plan_period_3"}],"formulary":{"formulary_id":"00027069","suppressed":false}},{"id":"NY-H3347-003-000","key":"H3347-003-000","plan_id":"H3347-003","segment":"000","year":2027,"state":"NY","counties":["Bronx","Dutchess","Kings","Livingston","Monroe","Nassau","New York","Ontario","Orange","Orleans","Putnam","Queens","Richmond","Rockland","Seneca","Suffolk","Westchester","Yates"],"carrier":"Elderplan","target":false,"parent":"Elderplan, Inc.","name":"Elderplan Advantage For Nursing Home Residents (HMO-POS I-SNP)","plan_type":"HMO-POS I-SNP","coverage":"MAPD","snp":"institutional","snp_label":"Institutional","snp_conditions":"Not Applicable","integration":"Not Applicable","sanctioned":"No","capacity":"No Limit","uploaded":false,"premium":33.7,"moop":9850.0,"drug_deductible":700.0,"stars":3.5,"low_income_drug_premium":0.0,"field_sources":{"premium":"Landscape: Monthly Consolidated Premium (Part C + D)","moop":"Landscape: In-Network Maximum Out-of-Pocket (MOOP) Amount","drug_deductible":"Landscape: Annual Part D Deductible Amount","giveback":"PBP pbp_Section_D: pbp_d_mco_pay_reduct_yn / pbp_d_mco_pay_reduct_amt"},"benefits":[{"category":"Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?","service":"","limit":null,"authorization":"","referral":"","network":"","cost":"No"},{"category":"Comprehensive dental","service":"Adjunctive General Services","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Endodontics","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Implant 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limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Prosthodontics, fixed","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Prosthodontics, removable","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Restorative services","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Cleaning","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Dental 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Confirm which benefits and eligibility rules apply.","source":"pbp_Section_D: pbp_d_combo_max_plan_ben_amt_1 / pbp_d_combo_max_plan_period_1"}],"formulary":{"formulary_id":"00027150","suppressed":false}},{"id":"NY-H6776-001-000","key":"H6776-001-000","plan_id":"H6776-001","segment":"000","year":2027,"state":"NY","counties":["Bronx","Kings","Nassau","New York","Queens","Richmond","Westchester"],"carrier":"ElderServe Health","target":false,"parent":"CareSource","name":"ElderServe Star (HMO I-SNP)","plan_type":"HMO I-SNP","coverage":"MAPD","snp":"institutional","snp_label":"Institutional","snp_conditions":"Not Applicable","integration":"Not Applicable","sanctioned":"No","capacity":"No Limit","uploaded":false,"premium":22.0,"moop":9850.0,"drug_deductible":700.0,"stars":null,"low_income_drug_premium":0.0,"field_sources":{"premium":"Landscape: Monthly Consolidated Premium (Part C + D)","moop":"Landscape: In-Network Maximum Out-of-Pocket (MOOP) Amount","drug_deductible":"Landscape: Annual 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the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Fluoride treatment","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Oral exam","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Other Diagnostic Services","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Other Preventive Services","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic procedures/lab 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coinsurance per item"},{"category":"Medical equipment/supplies","service":"Prosthetics (e.g., braces, artificial limbs)","limit":null,"authorization":"Yes","referral":"N/A","network":"In-Network","cost":"20% coinsurance per item"},{"category":"Medicare Dental Services","service":"Medicare Dental Services","limit":null,"authorization":"Yes","referral":"No","network":"In-Network","cost":"20% coinsurance"},{"category":"Medicare Part B drugs","service":"","limit":null,"authorization":"Yes","referral":"N/A","network":"In-Network","cost":"0-20% coinsurance (up to $35)"},{"category":"Medicare Part B drugs","service":"Chemotherapy","limit":null,"authorization":"Yes","referral":"N/A","network":"In-Network","cost":"0-20% coinsurance"},{"category":"Medicare Part B drugs","service":"Other Part B drugs","limit":null,"authorization":"Yes","referral":"N/A","network":"In-Network","cost":"0-20% coinsurance"},{"category":"Mental health services","service":"Inpatient hospital - 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coinsurance"},{"category":"Optional supplemental benefits?","service":"","limit":null,"authorization":"","referral":"","network":"","cost":"No"},{"category":"Other health plan deductibles?","service":"","limit":null,"authorization":"","referral":"","network":"","cost":"No"},{"category":"Outpatient hospital coverage","service":"","limit":null,"authorization":"Yes","referral":"No","network":"In-Network","cost":"20% coinsurance per visit"},{"category":"Preventive care","service":"","limit":null,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay"},{"category":"Rehabilitation services","service":"Occupational therapy visit","limit":null,"authorization":"No","referral":"No","network":"In-Network","cost":"20% coinsurance"},{"category":"Rehabilitation services","service":"Physical therapy and speech and language therapy visit","limit":null,"authorization":"No","referral":"No","network":"In-Network","cost":"20% coinsurance"},{"category":"Skilled Nursing Facility","service":"","limit":null,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0 copay"},{"category":"Transportation","service":"","limit":null,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Vision","service":"Contact lenses","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Vision","service":"Eyeglass frames","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Vision","service":"Eyeglass lenses","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Vision","service":"Eyeglasses (frames and 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Check eligible items and delivery rules.","source":"pbp_b13_other_services: pbp_b13b_maxplan_amt / pbp_b13b_otc_maxplan_per"},{"label":"Preventive dental maximum","amount":2850.0,"period":"Every year","note":"Check service limits; may share a limit with comprehensive dental.","source":"pbp_b16_dental: pbp_b16b_maxplan_pv_amt / pbp_b16b_maxplan_pv_per"},{"label":"Comprehensive dental maximum","amount":null,"period":"","note":"Shares the preventive dental limit; do not add the two amounts.","source":"pbp_b16_dental: pbp_b16c_maxplan_cmp_type"},{"label":"Combined eyewear maximum","amount":250.0,"period":"Every two years","note":"Combined eyewear allowance; check covered items and provider rules.","source":"pbp_b17_eye_exams_wear: pbp_b17b_comb_maxplan_amt / pbp_b17b_comb_maxplan_per"},{"label":"Hearing-aid maximum","amount":1300.0,"period":"Every two years","note":"Check whether the limit is per ear, device, or combined; network and device restrictions apply.","source":"pbp_b18_hearing_exams_aids: pbp_b18b_maxplan_amt / pbp_b18b_maxplan_per"}],"formulary":{"formulary_id":"00027262","suppressed":false}},{"id":"NY-H9678-002-000","key":"H9678-002-000","plan_id":"H9678-002","segment":"000","year":2027,"state":"NY","counties":["Bronx","Kings","Nassau","New York","Queens","Richmond","Rockland","Suffolk","Westchester"],"carrier":"Healthfirst Medicare Plan","target":false,"parent":"Healthfirst, Inc.","name":"Healthfirst Signature (PPO)","plan_type":"PPO","coverage":"MAPD","snp":"standard","snp_label":"Not Applicable","snp_conditions":"Not Applicable","integration":"Not Applicable","sanctioned":"No","capacity":"No Limit","uploaded":false,"premium":155.0,"moop":9850.0,"drug_deductible":700.0,"stars":3.0,"low_income_drug_premium":112.4,"field_sources":{"premium":"Landscape: Monthly Consolidated Premium (Part C + D)","moop":"Landscape: In-Network Maximum Out-of-Pocket (MOOP) Amount","drug_deductible":"Landscape: Annual Part D Deductible Amount","giveback":"PBP pbp_Section_D: pbp_d_mco_pay_reduct_yn / pbp_d_mco_pay_reduct_amt"},"benefits":[{"category":"Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?","service":"","limit":null,"authorization":"","referral":"","network":"","cost":"No"},{"category":"Comprehensive dental","service":"Adjunctive General Services","limit":1,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Adjunctive General Services","limit":1,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"$0-40 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Endodontics","limit":1,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive 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Surgery","limit":1,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Oral and Maxillofacial Surgery","limit":1,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"$0-100 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Orthodontics","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Periodontics","limit":1,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Periodontics","limit":1,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"$0-100 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Prosthodontics, fixed","limit":1,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Prosthodontics, fixed","limit":1,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"$0-100 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Prosthodontics, removable","limit":1,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Prosthodontics, removable","limit":1,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"$0-100 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Restorative services","limit":1,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Comprehensive dental","service":"Restorative services","limit":1,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"$0-100 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Cleaning","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Cleaning","limit":1,"authorization":"No","referral":"No","network":"Out-of-Network","cost":"$20 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Dental x-ray(s)","limit":1,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Dental x-ray(s)","limit":1,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Fluoride treatment","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Fluoride treatment","limit":1,"authorization":"No","referral":"No","network":"Out-of-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Oral exam","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Oral exam","limit":1,"authorization":"No","referral":"No","network":"Out-of-Network","cost":"$0-20 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Other Diagnostic Services","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Other Preventive Services","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Other Preventive Services","limit":1,"authorization":"No","referral":"No","network":"Out-of-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic procedures/lab services/imaging","service":"Diagnostic radiology services (e.g., MRI)","limit":null,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0-275 copay"},{"category":"Diagnostic procedures/lab services/imaging","service":"Diagnostic radiology services (e.g., MRI)","limit":null,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"30% coinsurance"},{"category":"Diagnostic procedures/lab services/imaging","service":"Diagnostic tests and procedures","limit":null,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0-75 copay"},{"category":"Diagnostic procedures/lab services/imaging","service":"Diagnostic tests and procedures","limit":null,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"$85 copay"},{"category":"Diagnostic procedures/lab services/imaging","service":"Lab services","limit":null,"authorization":"Yes","referral":"No","network":"In-Network","cost":"0-20% coinsurance"},{"category":"Diagnostic procedures/lab services/imaging","service":"Lab services","limit":null,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"$60 copay"},{"category":"Diagnostic procedures/lab services/imaging","service":"Outpatient x-rays","limit":null,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0-75 copay"},{"category":"Diagnostic procedures/lab services/imaging","service":"Outpatient x-rays","limit":null,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"$85 copay"},{"category":"Doctor visits","service":"Primary","limit":null,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"$0 copay"},{"category":"Doctor visits","service":"Primary","limit":null,"authorization":"N/A","referral":"N/A","network":"Out-of-Network","cost":"$50 copay per visit"},{"category":"Doctor visits","service":"Specialist","limit":null,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$0-40 copay per visit"},{"category":"Doctor visits","service":"Specialist","limit":null,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"$75 copay per visit"},{"category":"Emergency care/urgent care","service":"Emergency","limit":null,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"$115 copay per visit (always covered)"},{"category":"Emergency care/urgent care","service":"Urgent care","limit":null,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"$40 copay per visit (always covered)"},{"category":"Foot care (podiatry services)","service":"Foot exams and treatment","limit":null,"authorization":"No","referral":"No","network":"In-Network","cost":"$40 copay"},{"category":"Foot care (podiatry services)","service":"Foot exams and treatment","limit":null,"authorization":"No","referral":"No","network":"Out-of-Network","cost":"$75 copay"},{"category":"Foot care (podiatry services)","service":"Routine foot care","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$40 copay"},{"category":"Ground Ambulance","service":"","limit":null,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"$340 copay"},{"category":"Ground Ambulance","service":"","limit":null,"authorization":"N/A","referral":"N/A","network":"Out-of-Network","cost":"$340 copay"},{"category":"Health plan deductible","service":"","limit":null,"authorization":"","referral":"","network":"","cost":"$450 annual deductible"},{"category":"Hearing","service":"Fitting/evaluation","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Hearing","service":"Hearing aids","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Hearing","service":"Hearing aids - inner ear","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Hearing","service":"Hearing aids - outer ear","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Hearing","service":"Hearing aids - over the ear","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Hearing","service":"Hearing exam","limit":null,"authorization":"No","referral":"No","network":"In-Network","cost":"$40 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Hearing","service":"Hearing exam","limit":null,"authorization":"No","referral":"No","network":"Out-of-Network","cost":"$75 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Inpatient hospital coverage","service":"","limit":null,"authorization":"Yes","referral":"No","network":"In-Network","cost":"$540 per day for days 1 through 4$0 per day for days 5 through 90$0 per day for days 91 and beyond"},{"category":"Inpatient hospital coverage","service":"","limit":null,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"30% per stay"},{"category":"Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)","service":"","limit":null,"authorization":"","referral":"","network":"","cost":"$14,800 In and Out-of-network$9,850 In-network"},{"category":"Medical equipment/supplies","service":"Diabetes supplies","limit":null,"authorization":"Yes","referral":"N/A","network":"In-Network","cost":"$0 copay"},{"category":"Medical equipment/supplies","service":"Diabetes supplies","limit":null,"authorization":"Yes","referral":"N/A","network":"Out-of-Network","cost":"50% coinsurance per 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Confirm which benefits and eligibility rules apply.","source":"pbp_Section_D: pbp_d_combo_max_plan_ben_amt_1 / pbp_d_combo_max_plan_period_1"},{"label":"Shared benefit: FlexSpendCard-OTC/Copay/Fitness/HSD","amount":200.0,"period":"Every year","note":"One combined limit, not an additional allowance. Confirm which benefits and eligibility rules apply.","source":"pbp_Section_D: pbp_d_combo_max_plan_ben_amt_2 / pbp_d_combo_max_plan_period_2"}],"formulary":null},{"id":"PA-H5932-001-000","key":"H5932-001-000","plan_id":"H5932-001","segment":"000","year":2027,"state":"PA","counties":["Adams","Allegheny","Armstrong","Beaver","Bedford","Berks","Blair","Bradford","Butler","Cambria","Cameron","Carbon","Centre","Clarion","Clearfield","Clinton","Crawford","Cumberland","Dauphin","Elk","Erie","Fayette","Forest","Franklin","Fulton","Greene","Huntingdon","Indiana","Jefferson","Juniata","Lancaster","Lawrence","Lebanon","Lehigh","Lycoming","McKean","Mercer","Mifflin","Monroe","Montour","Northampton","Perry","Potter","Schuylkill","Snyder","Somerset","Sullivan","Susquehanna","Tioga","Union","Venango","Warren","Washington","Wayne","Westmoreland","Wyoming","York"],"carrier":"Highmark","target":true,"parent":"Highmark Health","name":"Highmark Wholecare Medicare Assured Diamond (HMO 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be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Cleaning","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Dental x-ray(s)","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Fluoride treatment","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Oral exam","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Diagnostic and Preventive dental","service":"Other 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item"},{"category":"Medicare Dental Services","service":"Medicare Dental Services","limit":null,"authorization":"No","referral":"No","network":"In-Network","cost":"20% coinsurance"},{"category":"Medicare Dental Services","service":"Medicare Dental Services","limit":null,"authorization":"No","referral":"No","network":"Out-of-Network","cost":"20% coinsurance"},{"category":"Medicare Part B drugs","service":"","limit":null,"authorization":"Yes","referral":"N/A","network":"In-Network","cost":"0-20% coinsurance (up to $35)"},{"category":"Medicare Part B drugs","service":"","limit":null,"authorization":"Yes","referral":"N/A","network":"Out-of-Network","cost":"$35 copay or 0-20% coinsurance"},{"category":"Medicare Part B drugs","service":"Chemotherapy","limit":null,"authorization":"Yes","referral":"N/A","network":"In-Network","cost":"0-20% coinsurance"},{"category":"Medicare Part B 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deductible for days 1 through 60$434 copay per day for days 61 through 90"},{"category":"Mental health services","service":"Outpatient group therapy visit","limit":null,"authorization":"No","referral":"No","network":"In-Network","cost":"20% coinsurance"},{"category":"Mental health services","service":"Outpatient group therapy visit","limit":null,"authorization":"No","referral":"No","network":"Out-of-Network","cost":"20% coinsurance"},{"category":"Mental health services","service":"Outpatient group therapy visit with a psychiatrist","limit":null,"authorization":"No","referral":"No","network":"In-Network","cost":"20% coinsurance"},{"category":"Mental health services","service":"Outpatient group therapy visit with a psychiatrist","limit":null,"authorization":"No","referral":"No","network":"Out-of-Network","cost":"20% coinsurance"},{"category":"Mental health services","service":"Outpatient individual therapy 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and speech and language therapy visit","limit":null,"authorization":"Yes","referral":"No","network":"In-Network","cost":"20% coinsurance"},{"category":"Rehabilitation services","service":"Physical therapy and speech and language therapy visit","limit":null,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"20% coinsurance"},{"category":"Skilled Nursing Facility","service":"","limit":null,"authorization":"Yes","referral":"No","network":"In-Network","cost":"In 2027 the amounts for each benefit period are:$0 copay for days 1 through 20$217 copay per day for days 21 through 100"},{"category":"Skilled Nursing Facility","service":"","limit":null,"authorization":"Yes","referral":"No","network":"Out-of-Network","cost":"In 2027 the amounts for each benefit period are:$0 copay for days 1 through 20$217 copay per day for days 21 through 100"},{"category":"Transportation","service":"","limit":null,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Vision","service":"Contact lenses","limit":1,"authorization":"No","referral":"No","network":"In-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Vision","service":"Contact lenses","limit":1,"authorization":"No","referral":"No","network":"Out-of-Network","cost":"$0 copay\n\nThere may be limits on how much the plan will provide."},{"category":"Vision","service":"Eyeglass frames","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Vision","service":"Eyeglass lenses","limit":1,"authorization":"N/A","referral":"N/A","network":"In-Network","cost":"Not covered\n\nThere may be limits on how much the plan will provide."},{"category":"Vision","service":"Eyeglasses (frames and 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