Prior Authorization Required" ["snf"]=> string(109) "$0.00 (days 1–20), $203.00 (days 21–100), $0.00 (days –)
Prior Authorization Required" ["pcp"]=> string(11) "$0.00 Copay" ["specialist"]=> string(59) "$20.00 Copay
Prior Authorization Required" ["urgent_care"]=> string(58) "$0.00 Copay
Prior Authorization Required" ["er"]=> string(58) "$0.00 Copay
Prior Authorization Required" ["ambulance_ground"]=> string(60) "$290.00 Copay
Prior Authorization Required" ["ambulance_air"]=> string(60) "$290.00 Copay
Prior Authorization Required" ["dental"]=> string(45) "$4,000.00 max
$4,000.00 max" ["vision"]=> string(48) "$0.00 Copay
$300.00/yr eyewear" ["hearing"]=> string(11) "Not Covered" ["rx"]=> array(2) { ["deductible"]=> string(11) "Not Covered" ["tiers"]=> array(0) { } } ["data_status"]=> string(2) "ok" }
🩺 Doctor’s Office Visits
Service | 2026 | 2025 |
---|---|---|
Primary | Coming soon | $0.00 Copay |
Specialist | Coming soon | $20.00 Copay Prior Authorization Required |
🏥 Emergency, Urgent, and Inpatient Hospital Coverage
Service | 2026 | 2025 |
---|---|---|
Emergency room care | Coming soon | $0.00 Copay Prior Authorization Required |
Urgent care | Coming soon | $0.00 Copay Prior Authorization Required |
Ground ambulance | Coming soon | $290.00 Copay Prior Authorization Required |
Inpatient hospital care | Coming soon | $295.00 (days 1–7), $0.00 (days 8–90), $0.00 (days –) Prior Authorization Required |
Skilled Nursing Facility | Coming soon | $0.00 (days 1–20), $203.00 (days 21–100), $0.00 (days –) Prior Authorization Required |
🦶 Foot Care
Service | 2026 | 2025 |
---|---|---|
Foot Exams and Treatments (Medicare-covered) | Coming soon | $0.00 Copay Prior Authorization Required |
Routine Foot Care | Coming soon | $0.00 Copay Prior Authorization Required |
💆 Chiropractic Care
Service | 2026 | 2025 |
---|---|---|
Medicare-covered chiropractic | Coming soon | $0.00 Copay Prior Authorization Required |
Routine chiropractic | Coming soon | $0.00 Copay Prior Authorization Required |
🧠 Mental Health Services
Service | 2026 | 2025 |
---|---|---|
Outpatient individual therapy | Coming soon | $15.00 Copay Prior Authorization Required |
Outpatient group therapy | Coming soon | $15.00 Copay Prior Authorization Required |
Inpatient psychiatric hospital care | Coming soon | $295.00 (days 1–7), $0.00 (days 8–90), $0.00 (days –) Prior Authorization Required |
🏋️ Rehabilitation Services
Service | 2026 | 2025 |
---|---|---|
Physical therapy and speech/language therapy | Coming soon | $0.00 Copay Prior Authorization Required |
Occupational therapy | Coming soon | $0.00 Copay Prior Authorization Required |
🧰 Medical Equipment and Supplies
Service | 2026 | 2025 |
---|---|---|
Diabetes supplies | Coming soon | $0.00 Copay Prior Authorization Required |
Durable medical equipment | Coming soon | $30.00 Copay 6 visits/yr, Prior Authorization Required |
Prosthetics | Coming soon | $0.00 Copay Prior Authorization Required |
🔬 Diagnostics, Lab Services, and Imaging
Service | 2026 | 2025 |
---|---|---|
Diagnostic radiology services | Coming soon | $0.00 Copay Prior Authorization Required |
Lab services | Coming soon | $0.00 Copay Prior Authorization Required |
Outpatient x-rays | Coming soon | $0.00 Copay |
Diagnostic tests and procedures | Coming soon | $0.00 Copay Prior Authorization Required |
💉 Medicare Part B Drugs
Service | 2026 | 2025 |
---|---|---|
Chemotherapy | Coming soon | $0.00 Copay Prior Authorization Required |
Other Part B drugs (Medicare-covered) | Coming soon | $0.00 Copay Prior Authorization Required |
Supplemental Benefits
🦷 Dental Services
Service | 2026 | 2025 |
---|---|---|
Medicare Covered Preventive Dental | Coming soon | $4,000.00 max $4,000.00 max |
Oral exam | Coming soon | $0.00 Copay |
Dental x-rays | Coming soon | $0.00 Copay |
Cleaning | Coming soon | $0.00 Copay |
Periodontics | Coming soon | $0.00 Copay |
Endodontics | Coming soon | $0.00 Copay |
Restorative Services | Coming soon | $0.00 Copay |
Dental Maximum | Coming soon | $4000.00 max |
👂 Hearing Aids and Services
Service | 2026 | 2025 |
---|---|---|
Fitting/evaluation | Coming soon | $0.00 Copay |
Hearing aids | Coming soon | $0.00 Copay |
Hearing exam | Coming soon | $0.00 max $0.00 max Prior Authorization Required |
Hearing Maximum | Coming soon | $0.00 max |
👓 Vision Services
Service | 2026 | 2025 |
---|---|---|
Medicare-covered eye exam | Coming soon | $0.00 max $0.00 max Prior Authorization Required |
Routine eye exam | Coming soon | $0.00 Copay |
Eyewear benefits | Coming soon | Not Covered |
Vision Eyewear Maximum | Coming soon | $300.00/yr eyewear |
Part D Plan Premium
The Part D prescription drug plan premium is included in your overall Medicare Advantage plan cost. However, additional expenses or subsidies may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help. LIS, provided by Social Security, helps those with limited income and resources to lower or eliminate Part D costs. LIS benefits are not part of Medicare Advantage coverage.
Basic Part D Premium: | ${part_d_basic_premium} |
---|---|
Supplemental Part D Premium: | ${part_d_supplemental_premium} |
Total Part D Premium: | ${part_d_total_premium} |
Low-Income Premium Subsidy: | ${part_d_lips_amount} |
Low-Income Premium Subsidy Paid by CMS: | ${part_d_lips_cms_pays} |
Low-Income Subsidy Premium: | ${part_d_lis_premium} |
For more details, visit the Social Security Extra Help program.
Prescription Drug Plan Deductible
This plan has a ${deductible} annual Part D deductible. You'll pay this deductible at the pharmacy before {carrier} starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, {name} may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
Drug Tier | Retail | Mail Order |
---|---|---|
*Deductible does not apply. |