🩺 Doctor’s Office Visits

• Primary: $0.00 Copay
• Specialist: $20.00 Copay
  Prior Authorization Required
• NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.

🏥 Emergency, Urgent, and Inpatient Hospital Coverage

• Emergency room care: % Coinsurance
  Prior Authorization Required
• Urgent care: $30.00 Copay
  Prior Authorization Required
• Ground ambulance: % Coinsurance
  Prior Authorization Required
• Inpatient hospital care: $225.00 (days 1–7), $0.00 (days 8–90), $0.00 (days –)
  Prior Authorization Required
• Skilled Nursing Facility: $0.00 (days 1–20), $200.00 (days 21–100), $0.00 (days –)
  Prior Authorization Required

🦶 Foot Care

• Foot Exams and Treatments (Medicare-covered): 20% Coinsurance
  Prior Authorization Required
• Routine Foot Care: $0.00 - $0.00 Copay
  Prior Authorization Required

💆 Chiropractic Care

• Medicare-covered chiropractic: 20% Coinsurance
  Prior Authorization Required
• Routine chiropractic: $0.00 Copay
  Prior Authorization Required

🧠 Mental Health Services

• Outpatient individual therapy: $30.00 Copay
  Prior Authorization Required
• Outpatient group therapy: $25.00 Copay
  Prior Authorization Required
• Inpatient psychiatric hospital care: $225.00 (days 1–7), $0.00 (days 8–90), $0.00 (days –)
  Prior Authorization Required

🏋️ Rehabilitation Services

• Physical therapy and speech and language therapy: $30.00 Copay
  Prior Authorization Required
• Occupational therapy: $30.00 Copay
  Prior Authorization Required

🧰 Medical Equipment and Supplies

• Diabetes supplies: $0.00 Copay
  Prior Authorization Required
• Durable medical equipment: $30.00 Copay
  Prior Authorization Required
• Prosthetics: % Coinsurance
  Prior Authorization Required

🔬 Diagnostics, Lab Services, and Imaging

• Diagnostic radiology services: $30.00 Copay
  Prior Authorization Required
• Lab services: $30.00 Copay
  Prior Authorization Required
• Outpatient x-rays: % Coinsurance
  Prior Authorization Required
• Diagnostic tests and procedures: $30.00 Copay
  Prior Authorization Required

💉 Medicare Part B Drugs

• Chemotherapy: $0.00 Copay
  Prior Authorization Required
• Other Part B drugs (Medicare-covered): $0.00 Copay
  Prior Authorization Required

Supplemental Benefits

🦷 Dental Services

• Medicare Covered Preventive Dental: $0.00 max
• Oral exam: $0.00 Copay
• Dental x-rays: $0.00 Copay
• Cleaning: $0.00 Copay
• Periodontics: $0.00 Copay
• Endodontics: Not Covered
• Restorative Services: Not Covered
Not Covered

👂 Hearing Aids and Services

• Fitting/evaluation: $0.00 Copay
• Hearing aids: $0.00 Copay
• Hearing exam: $0.00 max
  Prior Authorization Required

👓 Vision Services

• Medicare-covered eye exam: $0.00 max
  Prior Authorization Required
• Routine eye exam: $0.00 Copay
• Eyewear benefits: $0.00 Copay
$100/yr eyewear