🩺 Doctor’s Office Visits
- Primary: $0 Copay
- Specialist: $20 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: $30 Copay
Prior Authorization Required - Ground ambulance: $315 Copay
Prior Authorization Required - Inpatient hospital care: $280 (days 1–5), $0 (days 6–90), $ (days –)
Prior Authorization Required - Skilled Nursing Facility: $10 (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: 20% Coinsurance
Prior Authorization Required - Routine chiropractic: 20% 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: $280 (days 1–5), $0 (days 6–90), $ (days –)
Prior Authorization Required
🏋️ Rehabilitation Services
- Physical therapy and speech and language therapy: $30 Copay
- Occupational therapy: $30 Copay
Prior Authorization Required
🧰 Medical Equipment and Supplies
- Diabetes supplies: $0 Copay
Prior Authorization Required - Durable medical equipment: $30 Copay
Prior Authorization Required - Prosthetics: % Coinsurance
Prior Authorization Required
🔬 Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services: $30 Copay
Prior Authorization Required - Lab services: $30 Copay
Prior Authorization Required - Outpatient x-rays: % Coinsurance
- Diagnostic tests and procedures: $30 Copay
Prior Authorization Required
💉 Medicare Part B Drugs
- Chemotherapy: $0 Copay
Prior Authorization Required - Other Part B drugs (Medicare-covered): $2 Copay
Prior Authorization Required
Supplemental Benefits
🦷 Dental Services
- Medicare Covered Preventive Dental: $2500 max
- Oral exam: $0 Copay
- Dental x-rays: $0 Copay
- Cleaning: $0 Copay
- Periodontics: $0 Copay
- Endodontics: $0 Copay
- Restorative Services: $0 Copay $2500 max
👂 Hearing Aids and Services
- Fitting/evaluation: $0 Copay
- Hearing aids: $0 Copay
- Hearing exam: Not Covered
Prior Authorization Required
👓 Vision Services
- Medicare-covered eye exam: $75 max
Prior Authorization Required - Routine eye exam: $0 Copay
- Eyewear benefits: $0 Copay $250/yr eyewear