🩺 Doctor’s Office Visits
- Primary: $0.00 Copay
- Specialist: $15.00 Copay
- 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
- Urgent care: % Coinsurance
- Ground ambulance: $290.00 Copay
- Inpatient hospital care: $325.00 (days 1–6), $0.00 (days 7–90), $0.00 (days –)
- Skilled Nursing Facility: $0.00 (days 1–20), $214.00 (days 21–100), $0.00 (days –)
🦶 Foot Care
- Foot Exams and Treatments (Medicare-covered): 20% Coinsurance
- Routine Foot Care: $0.00 - $0.00 Copay
💆 Chiropractic Care
- Medicare-covered chiropractic: 20% Coinsurance
- Routine chiropractic: 20% Coinsurance
🧠 Mental Health Services
- Outpatient individual therapy: $15.00 Copay
- Outpatient group therapy: $15.00 Copay
- Inpatient psychiatric hospital care: $325.00 (days 1–5), $0.00 (days 6–90), $0.00 (days –)
🏋️ Rehabilitation Services
- Physical therapy and speech and language therapy: $45.00 Copay
- Occupational therapy: $40.00 Copay
🧰 Medical Equipment and Supplies
- Diabetes supplies: $0.00 Copay
- Durable medical equipment: $45.00 Copay
6 visits/yr - Prosthetics: % Coinsurance
🔬 Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services: $40.00 Copay
- Lab services: % Coinsurance
- Outpatient x-rays: % Coinsurance
- Diagnostic tests and procedures: % Coinsurance
💉 Medicare Part B Drugs
- Chemotherapy: $0.00 Copay
- Other Part B drugs (Medicare-covered): $10.00 Copay
Supplemental Benefits
🦷 Dental Services
- Medicare Covered Preventive Dental: $1,000.00 max
- Oral exam: $0.00 Copay
- Dental x-rays: $0.00 Copay
- Cleaning: $0.00 Copay
- Periodontics: $0.00 Copay
- Endodontics: $0.00 Copay
- Restorative Services: $0.00 Copay $1000 max
👂 Hearing Aids and Services
- Fitting/evaluation: $0.00 Copay
- Hearing aids: $0.00 Copay
- Hearing exam: $0.00 max
👓 Vision Services
- Medicare-covered eye exam: $75.00 max
- Routine eye exam: $0.00 Copay
- Eyewear benefits: $0.00 Copay $150/yr eyewear