Transcription of Your 2022 Medical Benefits Chart NYC Medicare Advantage ...
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Your 2022 Medical Benefits Chart NYC Medicare Advantage ...
Your 2022 Medical Benefits Chart NYC Medicare Advantage Plus Plan City of New York Y0114_22_3000419_I_C 06/24/2021 2022 Custom PPO Plan 0P_HCSPP500X12_MEALP56_C-TRP 07/28/2021 City of New York Covered services What you must pay for these covered services In-Network Out-of-Network Doctor and hospital choice You may go to doctors, specialists, and hospitals in or out of the network. You do not need a referral. Prior authorization* Benefit categories that include services that require prior authorization are marked with an asterisk (*).
• Prosthetic and orthotic devices (other than dental) that replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devices • Leg, arm, back and neck braces, trusses and artificial
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