🩺 Doctor’s Office Visits
| Service | 2026 | 2025 |
|---|---|---|
| Primary | Coming soon | Not Covered |
| Specialist | Coming soon | $15.00 Copay |
🏥 Emergency, Urgent, and Inpatient Hospital Coverage
| Service | 2026 | 2025 |
|---|---|---|
| Emergency room care | Coming soon | $0.00 - $375.00 Copay Prior Authorization Required |
| Urgent care | Coming soon | $35.00 Copay |
| Ground ambulance | Coming soon | $0.00 - $300.00 Copay Prior Authorization Required |
| Inpatient hospital care | Coming soon | $275.00 (days 1–5), $0.00 (days 6–90) Prior Authorization Required |
| Skilled Nursing Facility | Coming soon | $0.00 (days 1–20), $214.00 (days 21–60), $0.00 (days 61–100) Prior Authorization Required |
🦶 Foot Care
| Service | 2026 | 2025 |
|---|---|---|
| Foot Exams and Treatments (Medicare-covered) | Coming soon | 20% Coinsurance |
| Routine Foot Care | Coming soon | 0% - 20% Coinsurance Prior Authorization Required |
💆 Chiropractic Care
| Service | 2026 | 2025 |
|---|---|---|
| Medicare-covered chiropractic | Coming soon | 15% Coinsurance Prior Authorization Required |
| Routine chiropractic | Coming soon | 0% - 20% Coinsurance Prior Authorization Required |
🧠 Mental Health Services
| Service | 2026 | 2025 |
|---|---|---|
| Outpatient individual therapy | Coming soon | $25.00 Copay |
| Outpatient group therapy | Coming soon | $20.00 Copay |
| Inpatient psychiatric hospital care | Coming soon | $275.00 (days 1–5), $0.00 (days 6–90) Prior Authorization Required |
🏋️ Rehabilitation Services
| Service | 2026 | 2025 |
|---|---|---|
| Physical therapy and speech/language therapy | Coming soon | $45.00 Copay |
| Occupational therapy | Coming soon | $45.00 Copay Prior Authorization Required |
🧰 Medical Equipment and Supplies
| Service | 2026 | 2025 |
|---|---|---|
| Diabetes supplies | Coming soon | Not Covered Prior Authorization Required |
| Durable medical equipment | Coming soon | $45.00 Copay |
| Prosthetics | Coming soon | $0.00 - $45.00 Copay Prior Authorization Required |
🔬 Diagnostics, Lab Services, and Imaging
| Service | 2026 | 2025 |
|---|---|---|
| Diagnostic radiology services | Coming soon | $45.00 Copay Prior Authorization Required |
| Lab services | Coming soon | $45.00 - $50.00 Copay |
| Outpatient x-rays | Coming soon | $0.00 - $45.00 Copay |
| Diagnostic tests and procedures | Coming soon | $45.00 Copay |
💉 Medicare Part B Drugs
| Service | 2026 | 2025 |
|---|---|---|
| Chemotherapy | Coming soon | Not Covered Prior Authorization Required |
| Other Part B drugs (Medicare-covered) | Coming soon | Not Covered Prior Authorization Required |
Supplemental Benefits
🦷 Dental Services
| Service | 2026 | 2025 |
|---|---|---|
| Medicare Covered Preventive Dental | Coming soon | $250.00 max $250.00 max |
| Oral exam | Coming soon | Not Covered |
| Dental x-rays | Coming soon | Not Covered |
| Cleaning | Coming soon | Not Covered |
| Periodontics | Coming soon | Not Covered |
| Endodontics | Coming soon | Not Covered |
| Restorative Services | Coming soon | Not Covered |
| Dental Maximum | Coming soon | $250.00 max |
👂 Hearing Aids and Services
| Service | 2026 | 2025 |
|---|---|---|
| Fitting/evaluation | Coming soon | Not Covered |
| Hearing aids | Coming soon | $599.00 - $899.00 Copay |
| Hearing exam | Coming soon | Not Covered |
| Hearing Maximum | Coming soon | Not Covered |
👓 Vision Services
| Service | 2026 | 2025 |
|---|---|---|
| Medicare-covered eye exam | Coming soon | Not Covered |
| Routine eye exam | Coming soon | Not Covered |
| Eyewear benefits | Coming soon | Not Covered |
| Vision Eyewear Maximum | Coming soon | $250.00/yr eyewear |
Part D Plan Premium
The Part D prescription drug plan premium is included in your overall Medicare Advantage plan cost. However, additional expenses or subsidies may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help. LIS, provided by Social Security, helps those with limited income and resources to lower or eliminate Part D costs. LIS benefits are not part of Medicare Advantage coverage.
| Basic Part D Premium: | ${part_d_basic_premium} |
|---|---|
| Supplemental Part D Premium: | ${part_d_supplemental_premium} |
| Total Part D Premium: | ${part_d_total_premium} |
| Low-Income Premium Subsidy: | ${part_d_lips_amount} |
| Low-Income Premium Subsidy Paid by CMS: | ${part_d_lips_cms_pays} |
| Low-Income Subsidy Premium: | ${part_d_lis_premium} |
For more details, visit the Social Security Extra Help program.
Prescription Drug Plan Deductible
This plan has a ${deductible} annual Part D deductible. You'll pay this deductible at the pharmacy before {carrier} starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, {name} may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Tier 1<sup>*</sup> | 30-day: — 90-day: — | 30-day: — 90-day: — |
| Preferred Generic<sup>*</sup> | 30-day: — 90-day: — | 30-day: — 90-day: — |
| Tier 3 | 30-day: — 90-day: — | 30-day: — 90-day: — |
| Tier 4 | 30-day: — 90-day: — | 30-day: — 90-day: — |
| Tier 5 | 30-day: — 90-day: — | 30-day: — 90-day: — |
| *Deductible does not apply. | ||