🩺 Doctor’s Office Visits
- Primary: Not Covered
Referral Required - Specialist: $5.00 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: $25.00 Copay
Prior Authorization Required, Referral Required - Urgent care: Not Covered
Prior Authorization Required, Referral Required - Ground ambulance: $25.00 Copay
Prior Authorization Required, Referral Required - Inpatient hospital care: $25.00 (days 1–7), $0.00 (days 8–90)
Prior Authorization Required, Referral Required - Skilled Nursing Facility: $0.00 (days 1–20), $25.00 (days 21–100)
Prior Authorization Required, Referral Required
🦶 Foot Care
- Foot Exams and Treatments (Medicare-covered): 20% Coinsurance
Prior Authorization Required, Referral Required - Routine Foot Care: 0% - 20% Coinsurance
Prior Authorization Required, Referral Required
💆 Chiropractic Care
- Medicare-covered chiropractic: 0% - 15% Coinsurance
Prior Authorization Required, Referral Required - Routine chiropractic: 20% Coinsurance
Prior Authorization Required, Referral Required
🧠 Mental Health Services
- Outpatient individual therapy: $5.00 Copay
Prior Authorization Required, Referral Required - Outpatient group therapy: Not Covered
Prior Authorization Required, Referral Required - Inpatient psychiatric hospital care: $25.00 (days 1–7), $0.00 (days 8–90)
Prior Authorization Required, Referral Required
🏋️ Rehabilitation Services
- Physical therapy and speech and language therapy: $5.00 Copay
Referral Required - Occupational therapy: $5.00 Copay
Referral Required
🧰 Medical Equipment and Supplies
- Diabetes supplies: Not Covered
Prior Authorization Required, Referral Required - Durable medical equipment: $5.00 Copay
Referral Required - Prosthetics: $0.00 - $5.00 Copay
Referral Required
🔬 Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services: $5.00 Copay
Referral Required - Lab services: Not Covered
Prior Authorization Required, Referral Required - Outpatient x-rays: $0.00 - $5.00 Copay
Referral Required - Diagnostic tests and procedures: $5.00 Copay
Referral Required
💉 Medicare Part B Drugs
- Chemotherapy: Not Covered
Referral Required - Other Part B drugs (Medicare-covered): Not Covered
Referral Required
Supplemental Benefits
🦷 Dental Services
- Medicare Covered Preventive Dental: Not Covered
Referral Required - Oral exam: Not Covered
2 visits/yr, Referral Required - Dental x-rays: Not Covered
1 visits/yr, Referral Required - Cleaning: Not Covered
Referral Required - Periodontics: Not Covered
1 visits/yr, Referral Required - Endodontics: 50% Coinsurance
1 visits/yr, Referral Required - Restorative Services: 50% Coinsurance
1 visits/yr, Referral Required
Not Covered
Referral Required
👂 Hearing Aids and Services
- Fitting/evaluation: Not Covered
Referral Required - Hearing aids: Not Covered
1 visits/yr, Referral Required - Hearing exam: Not Covered
Referral Required
👓 Vision Services
- Medicare-covered eye exam: Not Covered
Referral Required - Routine eye exam: Not Covered
Referral Required - Eyewear benefits: Not Covered
Referral Required
Not Covered
$200.00/yr eyewear, Referral Required