🩺 Doctor’s Office Visits

• Primary: % - % Coinsurance
  Referral Required
• Specialist: $20.00 Copay
  Referral 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: $0.00 - $300.00 Copay
  Prior Authorization Required, Referral Required
• Urgent care: $20.00 Copay
  Prior Authorization Required, Referral Required
• Ground ambulance: $300.00 Copay
  Prior Authorization Required, Referral Required
• Inpatient hospital care: $325.00 (days 1–5), $0.00 (days 6–90)
  Prior Authorization Required, Referral Required
• Skilled Nursing Facility: $0.00 (days 1–20), $214.00 (days 21–100)
  Prior Authorization Required, Referral Required

🦶 Foot Care

• Foot Exams and Treatments (Medicare-covered): 20% Coinsurance
  Referral Required
• Routine Foot Care: 0% - 20% Coinsurance
  Prior Authorization Required, Referral Required

💆 Chiropractic Care

• Medicare-covered chiropractic: 20% Coinsurance
  Prior Authorization Required, Referral Required
• Routine chiropractic: 20% Coinsurance
  Prior Authorization Required, Referral Required

🧠 Mental Health Services

• Outpatient individual therapy: % - % Coinsurance
  Referral Required
• Outpatient group therapy: % - % Coinsurance
  Referral Required
• Inpatient psychiatric hospital care: $325.00 (days 1–5), $0.00 (days 6–90)
  Prior Authorization Required, Referral Required

🏋️ Rehabilitation Services

• Physical therapy and speech and language therapy: $35.00 Copay
  Referral Required
• Occupational therapy: $15.00 Copay
  Referral Required

🧰 Medical Equipment and Supplies

• Diabetes supplies: % - % Coinsurance
  Referral Required
• Durable medical equipment: $0.00 - $35.00 Copay
  Referral Required
• Prosthetics: $0.00 - $35.00 Copay
  Prior Authorization Required, Referral Required

🔬 Diagnostics, Lab Services, and Imaging

• Diagnostic radiology services: $15.00 Copay
  Referral Required
• Lab services: $20.00 Copay
  Prior Authorization Required, Referral Required
• Outpatient x-rays: $0.00 - $45.00 Copay
  Referral Required
• Diagnostic tests and procedures: $15.00 Copay
  Referral Required

💉 Medicare Part B Drugs

• Chemotherapy: 0% - 20% Coinsurance
  Referral Required
• Other Part B drugs (Medicare-covered): % - % Coinsurance
  Referral Required

Supplemental Benefits

🦷 Dental Services

• Medicare Covered Preventive Dental: $2,000.00 max
  $2,000.00 max
  Referral Required
• Oral exam: % - % Coinsurance
  Referral Required
• Dental x-rays: % - % Coinsurance
  Referral Required
• Cleaning: Not Covered
  Referral Required
• Periodontics: 50% Coinsurance
  Referral Required
• Endodontics: 50% Coinsurance
  Referral Required
• Restorative Services: Not Covered
  Referral Required
$2000.00 max

👂 Hearing Aids and Services

• Fitting/evaluation: % - % Coinsurance
  Referral Required
• Hearing aids: % - % Coinsurance
  Referral Required
• Hearing exam: Not Covered
  Referral Required

👓 Vision Services

• Medicare-covered eye exam: Not Covered
  Prior Authorization Required, Referral Required
• Routine eye exam: % - % Coinsurance
  Referral Required
• Eyewear benefits: % - % Coinsurance
  Referral Required
$150.00/yr eyewear