🩺 Doctor’s Office Visits

• Primary: $0.00 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: $0.00 - $300.00 Copay
  Prior Authorization Required
• Urgent care: $25.00 Copay
• Ground ambulance: $250.00 Copay
• Inpatient hospital care: Not Covered
  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
  Prior Authorization Required
• Routine Foot Care: 0% - 20% Coinsurance
  Prior Authorization Required

💆 Chiropractic Care

• Medicare-covered chiropractic: 0% - 20% Coinsurance
  Prior Authorization Required
• Routine chiropractic: 20% Coinsurance
  Prior Authorization Required

🧠 Mental Health Services

• Outpatient individual therapy: $0.00 Copay
• Outpatient group therapy: $0.00 Copay
• Inpatient psychiatric hospital care: $350.00 (days 1–5), $0.00 (days 6–90)
  Prior Authorization Required

🏋️ Rehabilitation Services

• Physical therapy and speech and language therapy: $10.00 - $30.00 Copay
• Occupational therapy: $40.00 Copay
  Prior Authorization Required

🧰 Medical Equipment and Supplies

• Diabetes supplies: $0.00 Copay
  Prior Authorization Required
• Durable medical equipment: $30.00 Copay
  4 visits/yr
• Prosthetics: $0.00 - $30.00 Copay

🔬 Diagnostics, Lab Services, and Imaging

• Diagnostic radiology services: $40.00 Copay
  Prior Authorization Required
• Lab services: $25.00 Copay
• Outpatient x-rays: 20% Coinsurance
  Prior Authorization Required
• Diagnostic tests and procedures: $40.00 Copay
  Prior Authorization Required

💉 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: $1,700.00 max
• Oral exam: $0.00 Copay
• Dental x-rays: $0.00 Copay
• Cleaning: $0.00 Copay
• Periodontics: $0.00 Copay
• Endodontics: $0.00 Copay
• Restorative Services: $0.00 Copay
$1700 max

👂 Hearing Aids and Services

• Fitting/evaluation: $0.00 Copay
• Hearing aids: $0.00 Copay
• Hearing exam: $0.00 max

👓 Vision Services

• Medicare-covered eye exam: $0.00 max
• Routine eye exam: $0.00 Copay
• Eyewear benefits: $0.00 Copay
$300/yr eyewear