Retirees and Dependents Over Age 65 enrolled in the Exclusive Care Select Medicare Coordination Plan. Call 1-800-962-1133 for additional information. The table consists of multiple rows with three columns, one column for Coverage Type, one for Tier 1 cost and one for tier 2 cost.

Retirees & Dependents Over Age 65 Exclusive Care Select Medicare Coordination  Call 1-800-962-1133 for additional information
Coverage Type	Tier 1- Exclusive Care Network	Tier 2- MultiPlan/PHCS Network or Providers who accepts Medicare Assignment
Annual Out-Pocket Maximum for Certain Services	$1,500/person $4,500/family	$2,500/person $7,500/family
Primary Care and Specialist Physician Office Visits	$10/primary care $20/specialist	$25/primary care $50/specialist
Inpatient Hospital Services (Mandatory Centers of Excellence apply)	90%	80% of Medicare allowable
Outpatient Facility Services   (Mandatory Centers of Excellence apply to some Outpatient Facility)	90%	80% of Medicare allowable
Hospital Emergency Room or Outpatient Facility (Mandatory Centers of Excellence apply to some Outpatient Facility)	$50 co-pay, then 90%	$100 co-pay, then 80%
Urgent Care Facility	$20 co-pay	$50 co-pay
Rehabilitative Therapy	90%	80% of Medicare allowable
Durable Medical Equipment	90%	80% of Medicare allowable
External Prosthetic Appliances	90%	80% of Medicare allowable
Home Health Services (up to 26 day/year)	90%	80% of Medicare allowable
Hospice Services	90%	80% of Medicare allowable
Skilled Nursing and Rehabilitation Facilities (100 visits maximum per member per contract year)	90%	80% of Medicare allowable
Laboratory and Radiology Services	90%	80% of Medicare allowable
Mental Health Inpatient Services (Mandatory Centers of Excellence apply)	90%	80% of Medicare allowable
Mental Health Outpatient Services (30 days maximum per member per contract year, unless Severe Mental Illness - Mandatory Centers of Excellence apply)	$20 co-pay
Substance Abuse Detoxification Inpatient Services (Mandatory Centers of Excellence apply)	90%	80% of Medicare allowable
Substance Abuse Detoxification Outpatient Services (30 days maximum per member per contract year – Mandatory Centers of Excellence apply)	$20 co-pay
Vision Care: Eye Exam	$10 co-pay	$25 co-pay
Vision Care: One Pair of Approved Glasses	Not Covered
Participating Retail Pharmacy (up to 30 day supply)	Generic: $15 co-pay Brand-name formulary: $25 co-pay Non-formulary Brand: $40 co-pay Significant or new therapeutic class drugs: 50%
Participating Mail-Order pharmacy (up to a 90 day supply)   Mail-order is MANDATORY for maintenance medications	Generic: $30 co-pay Brand-name formulary: $50 co-pay Non-formulary Brand: $80 co-pay
This is a summary of the frequently asked about benefits. This chart is not meant to be a comprehensive explanation of benefits, cost sharing, exclusions or limitations. For a complete explanation of benefits, please refer to the Summary Plan Document (SPD).