BlueCross BlueShield of Tennessee
Plan ID: H3015-1-0
2025 Shared Health Dual Plus (HMO D-SNP) H3015 — 001 — 0 is a Medicare Advantage plan with drug coverage. It has received a 3-out-of-5 star rating from CMS for 2025.
Learn more about Shared Health Dual Plus (HMO D-SNP) H3015 - 001 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.
3 / 5 stars for 2025
$39.10 /mo
Monthly premium
$590.00
Drug deductible
$9350.00
Out-of-pocket maximum (Out-of-Network)
Enroll online
Call to enroll
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!
2025 Shared Health Dual Plus (HMO D-SNP) H3015 — 001 — 0 is a HMO D-SNP offered in Mississippi by BlueCross BlueShield of Tennessee. It has a monthly premium of $39.10.
Important:
2025 Shared Health Dual Plus (HMO D-SNP) H3015 — 001 — 0 is a Dual-Eligible Special Needs Type plan. You can only enroll in this plan if you meet specific criteria.
Standard Part B Premium
$185.00
Part B premium reduction
- $0
Monthly Plan Premium
$39.10
Total Premium:
$224.10
Note:
The standard Medicare Part B premium for 2025 is $185.00. Your premium may differ based on factors like late enrollment, income (IRMAA), or disability status. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
Yes
Out-of-pocket maximum (In-Network)
N/A
Out-of-pocket maximum (Out-of-Network)
$9350.00
Out-of-pocket maximum (Combined)
N/A
Conditions Covered
None
Plan Organization:
BlueCross BlueShield of Tennessee
Plan Type:
HMO D-SNP
Location:
Mississippi
Drugs Covered:
Yes
Drug Formulary:
Pharmacies:
Doctors Link:
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Drug deductible
$590
Note:
This plan does not charge an annual deductible for all drugs. The $590.00 annual deductible only applies to drugs in certain tiers.
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Shared Health Dual Plus (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Benefit Type
Defined Standard
Prescription drug deductible
$590.00
This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.
Part D | LIS Full |
---|---|
$39.10 | $39.10 |
After you pay your $590.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2000.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
---|---|---|---|---|
1. Preferred Generic | - | - | - | - |
2. Standard Generic | - | - | - | - |
3. Preferred Brand | - | - | - | - |
4. Non-Preferred Drug | - | - | - | - |
5. Specialty Tier | - | - | - | - |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Shared Health Dual Plus (HMO D-SNP) also provides the following benefits.
Hearing Services benefits are covered.
Hearing Exams benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Hearing Exam Benefits have a Coinsurance
Routine Hearing Exams
Minimum coinsurance
20
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
Yes
Maximum amount
0.00
Periodicity
Other, Describe
Description
Benefit includes 1 routine hearing exam annually at $0 cost-sharing.
Routine Hearing Exams benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Fitting/Evaluation for Hearing Aid benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Prescription Hearing Aids benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Maximum enrollee out-of-pocket cost type
Plan-specified amount per period
Periodicity
Other, Describe
Description
1 hearing aid per ear every 3 years.
Service maximum plan benefit coverage
No
Prescription Hearing Aids (all types) benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
2
Periodicity
Every three years
Not covered.
Not covered.
Not covered.
Not covered.
Vision Services benefits are covered.
Eye Exams benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Eye Exams have a Coinsurance
Routine Eye Exams
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Eye Exams benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Eyewear benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Eyewear Benefits have a Coinsurance
Contact lenses
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
Yes
Maximum plan benefit coverage type
Plan-specified amount per period
Do you offer a Combined Max Plan Benefit Coverage Amount for all Eyewear?
Yes
Combined maximum amount
300.00
Periodicity
Every year
Contact Lenses benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of pairs
1
Periodicity
Other, Describe
Description
$300 allowance per year for glasses and/or contact lenses and fittings.
Eyeglasses (lenses and frames) benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of pairs
1
Periodicity
Other, Describe
Description
$300 allowance per year for glasses and/or contact lenses and fittings.
Eyeglass lenses benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of pairs
1
Periodicity
Other, Describe
Description
$300 allowance per year for glasses and/or contact lenses and fittings.
Eyeglass frames benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of eyeglass frames
1
Periodicity
Other, Describe
Description
$300 allowance per year for glasses and/or contact lenses and fittings.
Not covered.
Dental Services benefits are covered.
Medicare Dental Services benefits are covered.
Other Dental Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
Yes
Maximum amount
4000.00
Periodicity
Every year
Oral Exams benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Every six months
Dental X-Rays benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of X-Rays
1
Periodicity
Other, Describe
Description
No more than one full mouth set of X-rays every 36 months. No more than four bitewing films every 12 months.
Other Diagnostic Dental Services benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Every year
Prophylaxis (Cleaning) benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Every six months
Fluoride Treatment benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Every six months
Other Preventive Dental Services benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
No more than one recementation every 12 months. No more than one sealant per tooth per lifetime.
Orthodontic Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
Yes
Maximum plan benefit coverage type
Covered under Diagnostic and Preventive Dental (16b)
Restorative Services benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
No more than one amalgam or resin restoration per tooth surface every 12 months.
Not covered.
Endodontics benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
For primary teeth only.
Periodontics benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
No more than one periodontal scaling and root planing per quadrant every 24 months. No more than one full mouth debridement per lifetime. No more than one cleaning or periodontal maintenance procedure
Prosthodontics, removable benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Replacement of removable dentures covered only after 60 months from the date of initial placement.
Not covered.
Not covered.
Prosthodontics, fixed benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Crown and bridge repair and recementation covered separately only after 12 months from the date of initial placement. Denture adjustments are covered separately from the denture only after 6 months.
Oral and Maxillofacial Surgery benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Not covered.
Home Infusion bundled Services benefits are covered.
Cost Sharing:
More Details:
Which Medicare Part B Rx Drugs have a Coinsurance
Medicare Part B Chemotherapy/Radiation Drugs, Other Medicare Part B Drugs
Does this plan have a service specific maximum enrollee out-of-pocket cost (MOOP)?
No
Does the plan offer step therapy?
Yes
Does the benefit step from?
Part B to Part D
Does the plan provide Part D home infusion drugs as part of a bundled service as a mandatory supplemental benefit?
No
Insulin benefits are covered.
Medicare Part B Insulin Drugs benefits are covered.
Cost Sharing:
More Details:
Does the Part B drugs - Insulin cost sharing count towards any plan-level deductible?
No
Medicare Part B Chemotherapy/Radiation Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Other Medicare Part B Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Preventive Services benefits are covered.
Medicare-covered Zero Dollar Preventive Services benefits are covered.
Not covered.
Additional Preventive Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a service-specific Maximum Plan Benefit Coverage amount for Other Defined Supplemental Benefits?
No
Not covered.
Not covered.
Personal Emergency Response System (PERS) benefits are covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Fitness Benefit benefits are covered.
More Details:
Type of Fitness Benefit offered
Memory Fitness
Not covered.
Not covered.
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) benefits are covered.
Not covered.
Not covered.
Kidney Disease Education Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Other Preventive Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Coinsurance
Medicare-covered Glaucoma Screening, Medicare-covered Diabetes Self-Management Training, Medicare-covered Barium Enemas, Medicare-covered Digital Rectal Exams, Medicare-covered EKG following Welcome Visit
Is a referral required for any Services?
No
Glaucoma Screening benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Diabetes Self-Management Training benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Barium Enemas benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Digital Rectal Exams benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
EKG following Welcome Visit benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Other Services benefits are covered.
Acupuncture benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Is this benefit unlimited for Number of Treatments?
No
Limit for Number of Treatments
20
Periodicity
Every year
Is there a maximum plan benefit coverage amount?
No
Over-the-Counter (OTC) Items benefits are covered.
More Details:
Does the plan provide Over-The-Counter (OTC) Items as a supplemental benefit under Part C?
Yes
Is there a maximum plan benefit coverage amount?
Yes
Maximum plan benefit coverage amount
200.00
Periodicity
Every month
Does your Maximum Plan Benefit Coverage amount carry forward to the next period if it is unused?
No
Plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit?
Yes
The Nicotine Replacement Therapy (NRT) being offered does not duplicate any Part D OTC or formulary drugs.
The Nicotine Replacement Therapy (NRT) being offered does not duplicate any Part D OTC or formulary drugs.
Plan offers Naloxone coverage as a Part C OTC benefit?
Yes
Does this cover all of the drugs on the CMS OTC list which may be found in Chapter 4 of the Medicare Managed Care Manual
Yes
Meal Benefit benefits are covered.
More Details:
Does the plan provide a limited duration Meal Benefit as a supplemental benefit under Part C? Note: Only primarily health-related meals offered in accordance with Chapter 4 of the MMCM should be entered in this section.
Yes
Type of primarily health related meals benefit offered
For a chronic illness
Is there a maximum plan benefit coverage amount?
Yes
Maximum plan benefit coverage amount
0.00
Periodicity
Other, Describe
Description
Our plan covers 14 meals following an acute inpatient or SNF discharge stay to a home setting. There is not a limit to the number of discharges for meals. Must use designated vendor.
Not covered.
Other Services benefits are covered.
More Details:
Is Authorization required for one or more Additional Services?
No
Is a referral required for one or more Additional Services?
No
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Not covered.
Dialysis Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Equipment benefits are covered.
Durable Medical Equipment (DME) benefits are covered.
More Details:
Is there a coinsurance?
Yes
Minimum coinsurance
20
Maximum coinsurance
20
Is there a copayment ?
No
Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?
No
Authorization required for this benefit?
No
Not covered.
Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered.
More Details:
Is there a coinsurance?
Yes
Which Prosthetics/Medical Supplies have a Coinsurance
Medicare-covered Prosthetic Devices, Medicare-covered Medical Supplies
Is there a copayment ?
No
Authorization required for this benefit?
No
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Supplies benefits are covered.
Cost Sharing:
Diabetic Equipment benefits are covered.
Cost Sharing:
More Details:
Which Diabetic Supplies and Services have a Coinsurance
Medicare-covered Diabetic Supplies, Medicare-covered Diabetic Therapeutic Shoes or Inserts
Do you limit Diabetic supplies and services to those from specified manufacturers
Yes
Diabetic Supplies benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Diabetic Therapeutic Shoes/Inserts benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Ambulance and Transportation Services benefits are covered.
All Ambulance Services benefits are covered. Prior Authorization is required.
More Details:
Is there a coinsurance?
Yes
Which Services have a Coinsurance
Medicare-covered Ground Ambulance Services, Medicare-covered Air Ambulance Services
Is this Coinsurance waived if admitted to hospital?
No
Is there a copayment ?
No
Ground Ambulance Services benefits are covered.
Cost Sharing:
Air Ambulance Services benefits are covered.
Cost Sharing:
Transportation Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Enhanced benefit (10b)
Plan Approved Health-related Location
Is there a service specific maximum plan benefit coverage amount?
No
Transportation Services - Plan Approved Health-related Location benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Type of transportation
One-way
Mode of Transportation
Rideshare Services, Bus/Subway, Van, Medical Transport, Other, Describe
Not covered.
Outpatient Services benefits are covered.
All Outpatient Hospital Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Coinsurance
Medicare-covered Outpatient Hospital Services, Medicare-covered Observation Services
Outpatient Hospital Services benefits are covered.
Cost Sharing:
Observation Services benefits are covered.
Cost Sharing:
Ambulatory Surgical Center (ASC) Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Outpatient Substance Abuse Services benefits are covered.
Cost Sharing:
More Details:
Which Outpatient Substance Abuse services have a Coinsurance
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Group Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Outpatient Blood Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Enhanced benefit
Three (3) Pint Deductible Waived
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Outpatient Diagnostic Procedures/Tests/Lab Services have a Coinsurance
Medicare-covered Diagnostic Procedures/Tests, Medicare-covered Lab Services
Is there a copayment?
No
Diagnostic Procedures/Tests benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Lab Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
All Radiological Services benefits are covered.
Cost Sharing:
More Details:
Which Outpatient Diagnostic/Therapeutic Radiological Services have a Coinsurance
Medicare-covered Diagnostic Radiological Services, Medicare-covered Therapeutic Radiological Services, Medicare-covered X-Ray Services
Is there a copayment?
No
Diagnostic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Therapeutic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Outpatient X-Ray Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Primary Care benefits are covered.
Primary Care Physician Services benefits are covered.
Cost Sharing:
Chiropractic Services benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
Cost Sharing:
More Details:
Which Chiropractic Services have a Coinsurance
Routine Care
Is there a maximum plan benefit coverage amount?
No
Routine Chiropractic Care benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Visits
12
Periodicity
Every year
Occupational Therapy Services benefits are covered.
More Details:
Is there a coinsurance?
Yes
Minimum coinsurance
20
Maximum coinsurance
20
Is there a copayment ?
No
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Physician Specialist Services benefits are covered.
Cost Sharing:
Mental Health Specialty Services benefits are covered.
Cost Sharing:
More Details:
Which Mental Health Specialty Services have a Coinsurance
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Group Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Podiatry Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Enhanced benefits (7f)
Routine Foot Care
Is this benefit unlimited?
No
Visits
6
Periodicity
Every year
Which Podiatry Services have a Coinsurance
Routine Foot Care
Minimum coinsurance
20
Maximum coinsurance
20
Is there a maximum plan benefit coverage amount?
No
Other Health Care Professional benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Psychiatric Services benefits are covered.
Cost Sharing:
More Details:
Which Psychiatric Services have a Coinsurance
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Group Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Physical Therapy and Speech-Language Pathology Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
Yes
Is there a copayment ?
No
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Additional Telehealth Benefits benefits are covered.
Opioid Treatment Program Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Home Health Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment ?
No
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Not covered.
Not covered.
Partial Hospitalization benefits are covered. Prior Authorization is required.
Cost Sharing:
Emergency Services benefits are covered.
Emergency Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
Yes
Is the coinsurance for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Hours
Enter number of days or hours
24
Is there a copayment?
No
Maximum per visit amount
110.00
Does the cost sharing count towards any plan-level deductible?
No
Urgently Needed Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
Yes
Is the coinsurance for Medicare-covered benefits waived if admitted to hospital?
No
Is there a copayment?
No
Maximum per visit amount
45.00
Does the cost sharing count towards any plan-level deductible?
No
Worldwide Emergency Services benefits are covered.
Not covered.
Not covered.
Not covered.
Cardiac Rehabilitation Services benefits are covered.
Cost Sharing:
More Details:
Which Cardiac and Pulmonary Rehabilitation Services have a Coinsurance
Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, Additional Cardiac Rehabilitation Services
Not covered.
Not covered.
Not covered.
Not covered.
Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization is required.
Cost Sharing:
Days 1-20: | Days 21-100: | |
---|---|---|
Copayment | 0.00 | 214.00 |
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
No
Do you allow less than 3 day inpatient hospital stay prior to SNF admission?
Yes
Days
Zero
Do you charge the Medicare-defined cost share for tier 1?
No
Periodicity
Original Medicare
Not covered.
Not covered.
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
2045.00
Periodicity
Original Medicare
Not covered.
Not covered.
Not covered.
Inpatient Hospital Psychiatric benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
2036.00
Periodicity
Original Medicare
Not covered.
Not covered.
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