🩺 Doctor’s Office Visits
- Primary: $0 Copay
- Specialist: $0 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: $35 Copay
Prior Authorization Required - Ground ambulance: $315 Copay
Prior Authorization Required - Inpatient hospital care: $400 (days 1–5), $0 (days 6–90), $ (days –)
Prior Authorization Required - Skilled Nursing Facility: $0 (days 1–20), $214 (days 21–100), $ (days –)
Prior Authorization Required
🦶 Foot Care
- Foot Exams and Treatments (Medicare-covered): 20% Coinsurance
Prior Authorization Required - Routine Foot Care: $ - $ Copay
Prior Authorization Required
💆 Chiropractic Care
- Medicare-covered chiropractic: $0 Copay
Prior Authorization Required - Routine chiropractic: 10% Coinsurance
Prior Authorization Required
🧠 Mental Health Services
- Outpatient individual therapy: $15 Copay
Prior Authorization Required - Outpatient group therapy: $15 Copay
Prior Authorization Required - Inpatient psychiatric hospital care: $400 (days 1–4), $0 (days 5–90), $ (days –)
Prior Authorization Required
🏋️ Rehabilitation Services
- Physical therapy and speech and language therapy: $40 Copay
- Occupational therapy: $40 Copay
Prior Authorization Required
🧰 Medical Equipment and Supplies
- Diabetes supplies: $0 Copay
Prior Authorization Required - Durable medical equipment: $40 Copay
Prior Authorization Required - Prosthetics: % Coinsurance
Prior Authorization Required
🔬 Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services: $40 Copay
Prior Authorization Required - Lab services: $35 Copay
Prior Authorization Required - Outpatient x-rays: % Coinsurance
- Diagnostic tests and procedures: % Coinsurance
Prior Authorization Required
💉 Medicare Part B Drugs
- Chemotherapy: $0 Copay
Prior Authorization Required - Other Part B drugs (Medicare-covered): $10 Copay
Prior Authorization Required
Supplemental Benefits
🦷 Dental Services
- Medicare Covered Preventive Dental: Not Covered
- Oral exam: Not Covered
- Dental x-rays: Not Covered
- Cleaning: Not Covered
- Periodontics: Not Covered
- Endodontics: Not Covered
- Restorative Services: Not Covered Not Covered
👂 Hearing Aids and Services
- Fitting/evaluation: Not Covered
- Hearing aids: Not Covered
- Hearing exam: $40 Copay
Prior Authorization Required
👓 Vision Services
- Medicare-covered eye exam: % Coinsurance
Prior Authorization Required - Routine eye exam: Not Covered
- Eyewear benefits: Not Covered Not Covered