🩺 Doctor’s Office Visits
- Primary: Not Covered
- Specialist: $18.00 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: $200.00 Copay
Prior Authorization Required - Urgent care: $25.00 Copay
Prior Authorization Required - Ground ambulance: $50.00 - $270.00 Copay
Prior Authorization Required - Inpatient hospital care: $0.00 (days –), $0.00 (days –), $0.00 (days –)
Prior Authorization Required - Skilled Nursing Facility: $10.00 (days 1–20), $214.00 (days 21–100), $0.00 (days –)
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: Not Covered
- Outpatient group therapy: Not Covered
- Inpatient psychiatric hospital care: $0.00 (days –), $0.00 (days –), $0.00 (days –)
Prior Authorization Required
🏋️ Rehabilitation Services
- Physical therapy and speech and language therapy: $25.00 Copay
- Occupational therapy: $25.00 Copay
🧰 Medical Equipment and Supplies
- Diabetes supplies: Not Covered
Prior Authorization Required - Durable medical equipment: $25.00 Copay
4 visits/yr - Prosthetics: $25.00 Copay
🔬 Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services: $25.00 Copay
- Lab services: $25.00 Copay
Prior Authorization Required - Outpatient x-rays: $0.00 - $25.00 Copay
- Diagnostic tests and procedures: $25.00 Copay
💉 Medicare Part B Drugs
- Chemotherapy: 0% - 20% Coinsurance
Prior Authorization Required - Other Part B drugs (Medicare-covered): 20% Coinsurance
Supplemental Benefits
🦷 Dental Services
- Medicare Covered Preventive Dental: $0.00 max
- Oral exam: Not Covered
- Dental x-rays: Not Covered
- Cleaning: Not Covered
- Periodontics: 30% Coinsurance
- Endodontics: 30% Coinsurance
- Restorative Services: 30% Coinsurance Not Covered
👂 Hearing Aids and Services
- Fitting/evaluation: Not Covered
- Hearing aids: $690.00 - $1,890.00 Copay
- Hearing exam: $0.00 max
👓 Vision Services
- Medicare-covered eye exam: $0.00 max
- Routine eye exam: Not Covered
- Eyewear benefits: Not Covered $225.00/yr eyewear