🩺 Doctor’s Office Visits

• Primary: $15 Copay
• Specialist: $15 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: $0 - $620 Copay
  Prior Authorization Required
• Urgent care: $20 - $35 Copay
  Prior Authorization Required
• Ground ambulance: $315 Copay
  Prior Authorization Required
• Inpatient hospital care: $450 (days 1–5), $0 (days 6–90)
  Prior Authorization Required
• Skilled Nursing Facility: $0 (days 1–20), $214 (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: 11% Coinsurance
  Prior Authorization Required
• Routine chiropractic: 11% 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: $450 (days 1–4), $0 (days 5–90)
  Prior Authorization Required

🏋️ Rehabilitation Services

• Physical therapy and speech and language therapy: $50 Copay
• Occupational therapy: $40 Copay
  Prior Authorization Required

🧰 Medical Equipment and Supplies

• Diabetes supplies: Not Covered
  Prior Authorization Required
• Durable medical equipment: $50 Copay
  Prior Authorization Required
• Prosthetics: $15 - $50 Copay
  Prior Authorization Required

🔬 Diagnostics, Lab Services, and Imaging

• Diagnostic radiology services: $40 Copay
  Prior Authorization Required
• Lab services: $20 - $35 Copay
  Prior Authorization Required
• Outpatient x-rays: $0 - $50 Copay
• Diagnostic tests and procedures: $40 - $100 Copay
  Prior Authorization Required

💉 Medicare Part B Drugs

• Chemotherapy: 10% Coinsurance
  Prior Authorization Required
• Other Part B drugs (Medicare-covered): $10 Copay
  Prior Authorization Required

Supplemental Benefits

🦷 Dental Services

• Medicare Covered Preventive Dental: $3000 max
• Oral exam: Not Covered
• Dental x-rays: Not Covered
• Cleaning: Not Covered
• Periodontics: Not Covered
• Endodontics: Not Covered
• Restorative Services: Not Covered
$3000 max

👂 Hearing Aids and Services

• Fitting/evaluation: Not Covered
• Hearing aids: $699 - $999 Copay
• Hearing exam: Not Covered
  Prior Authorization Required

👓 Vision Services

• Medicare-covered eye exam: $75 max
  Prior Authorization Required
• Routine eye exam: Not Covered
• Eyewear benefits: Not Covered
$200/yr eyewear