🩺 Doctor’s Office Visits
- Primary: $5.00 Copay
- Specialist: $20.00 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: $0.00 - $275.00 Copay
Prior Authorization Required - Urgent care: $35.00 Copay
- Ground ambulance: $285.00 Copay
- Inpatient hospital care: $295.00 (days 1–5), $0.00 (days 6–90)
Prior Authorization Required - Skilled Nursing Facility: $10.00 (days 1–20), $214.00 (days 21–100)
Prior Authorization Required
🦶 Foot Care
- Foot Exams and Treatments (Medicare-covered): 20% Coinsurance
Prior Authorization Required - 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: $15.00 Copay
- Outpatient group therapy: $25.00 Copay
- Inpatient psychiatric hospital care: $295.00 (days 1–5), $0.00 (days 6–90)
Prior Authorization Required
🏋️ Rehabilitation Services
- Physical therapy and speech and language therapy: $0.00 - $45.00 Copay
- Occupational therapy: $40.00 Copay
Prior Authorization Required
🧰 Medical Equipment and Supplies
- Diabetes supplies: $0.00 Copay
Prior Authorization Required - Durable medical equipment: $45.00 Copay
6 visits/yr - Prosthetics: $0.00 - $45.00 Copay
🔬 Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services: $40.00 Copay
Prior Authorization Required - Lab services: $35.00 Copay
- Outpatient x-rays: 20% Coinsurance
Prior Authorization Required - Diagnostic tests and procedures: $40.00 Copay
Prior Authorization Required
💉 Medicare Part B Drugs
- Chemotherapy: 0% - 20% Coinsurance
Prior Authorization Required - Other Part B drugs (Medicare-covered): $10.00 Copay
Supplemental Benefits
🦷 Dental Services
- Medicare Covered Preventive Dental: $2,000.00 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 $2000 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: $0.00 max
- Routine eye exam: $0.00 Copay
- Eyewear benefits: $0.00 Copay $270/yr eyewear