🩺 Doctor’s Office Visits

• Primary: Not Covered
• 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: $375.00 Copay
  Prior Authorization Required
• Urgent care: $40.00 Copay
• Ground ambulance: $350.00 Copay
• Inpatient hospital care: $425.00 (days 1–7), $0.00 (days 8–90)
  Prior Authorization Required
• Skilled Nursing Facility: $0.00 (days 1–20), $214.00 (days 21–100)
  Prior Authorization Required

🦶 Foot Care

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

💆 Chiropractic Care

• Medicare-covered chiropractic: 0% - 20% Coinsurance
  Prior Authorization Required
• Routine chiropractic: 20% Coinsurance
  Prior Authorization Required

🧠 Mental Health Services

• Outpatient individual therapy: $0.00 Copay
• Outpatient group therapy: $0.00 Copay
• Inpatient psychiatric hospital care: $300.00 (days 1–7), $0.00 (days 8–90)
  Prior Authorization Required

🏋️ Rehabilitation Services

• Physical therapy and speech and language therapy: $50.00 Copay
• Occupational therapy: $20.00 Copay

🧰 Medical Equipment and Supplies

• Diabetes supplies: Not Covered
  Prior Authorization Required
• Durable medical equipment: $50.00 Copay
  Prior Authorization Required
• Prosthetics: $0.00 - $50.00 Copay
  Prior Authorization Required

🔬 Diagnostics, Lab Services, and Imaging

• Diagnostic radiology services: $20.00 Copay
• Lab services: $40.00 Copay
• Outpatient x-rays: Not Covered
• Diagnostic tests and procedures: Not Covered

💉 Medicare Part B Drugs

• Chemotherapy: Not Covered
  Prior Authorization Required
• Other Part B drugs (Medicare-covered): Not Covered
  Prior Authorization Required

Supplemental Benefits

🦷 Dental Services

• Medicare Covered Preventive Dental: $1500.00 max
  $1500.00 max
• Oral exam: Not Covered
  2 visits/yr
• Dental x-rays: Not Covered
  1 visits/yr
• Cleaning: Not Covered
• Periodontics: Not Covered
  1 visits/yr
• Endodontics: Not Covered
  1 visits/yr
• Restorative Services: Not Covered
$1500.00 max
$1500.00 max

👂 Hearing Aids and Services

• Fitting/evaluation: $0.00 - $50.00 Copay
  1 visits/yr
• Hearing aids: Not Covered
  1 visits/yr
• Hearing exam: Not Covered

👓 Vision Services

• Medicare-covered eye exam: Not Covered
• Routine eye exam: Not Covered
  1 visits/yr
• Eyewear benefits: Not Covered
Not Covered
$150.00/yr eyewear