🩺 Doctor’s Office Visits
- Primary: $5.00 Copay
- 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: $400.00 Copay
Prior Authorization Required - Urgent care: $35.00 Copay
Prior Authorization Required - Ground ambulance: $300.00 Copay
Prior Authorization Required - Inpatient hospital care: $400.00 (days 1–5), $0.00 (days 6–90)
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: 20% Coinsurance
Prior Authorization Required - Routine chiropractic: 20% Coinsurance
Prior Authorization Required
🧠 Mental Health Services
- Outpatient individual therapy: $15.00 Copay
- Outpatient group therapy: $15.00 Copay
- Inpatient psychiatric hospital care: $374.00 (days 1–5), $0.00 (days 6–90)
Prior Authorization Required
🏋️ Rehabilitation Services
- Physical therapy and speech and language therapy: $45.00 Copay
- Occupational therapy: 20% Coinsurance
Prior Authorization Required
🧰 Medical Equipment and Supplies
- Diabetes supplies: Not Covered
Prior Authorization Required - Durable medical equipment: $45.00 Copay
- Prosthetics: $45.00 Copay
🔬 Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services: 20% Coinsurance
Prior Authorization Required - Lab services: $35.00 Copay
Prior Authorization Required - Outpatient x-rays: 20% Coinsurance
- Diagnostic tests and procedures: 20% Coinsurance
💉 Medicare Part B Drugs
- Chemotherapy: $5.00 Copay
Prior Authorization Required - Other Part B drugs (Medicare-covered): 20% Coinsurance
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: $499.00 - $799.00 Copay
- Hearing exam: Not Covered
👓 Vision Services
- Medicare-covered eye exam: Not Covered
- Routine eye exam: Not Covered
- Eyewear benefits: Not Covered $350.00/yr eyewear