🩺 Doctor’s Office Visits

• Primary: Not Covered
• Specialist: $20 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 - $250 Copay
  Prior Authorization Required
• Urgent care: $20 Copay
  Prior Authorization Required
• Ground ambulance: $315 Copay
  Prior Authorization Required
• Inpatient hospital care: $280 (days 1–5), $0 (days 6–90)
  Prior Authorization Required
• Skilled Nursing Facility: $20 (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: 15% Coinsurance
  Prior Authorization Required
• Routine chiropractic: 20% Coinsurance
  Prior Authorization Required

🧠 Mental Health Services

• Outpatient individual therapy: $20 Copay
  Prior Authorization Required
• Outpatient group therapy: $20 Copay
  Prior Authorization Required
• Inpatient psychiatric hospital care: $280 (days 1–5), $0 (days 6–90)
  Prior Authorization Required

🏋️ Rehabilitation Services

• Physical therapy and speech and language therapy: $25 Copay
• Occupational therapy: $25 Copay
  Prior Authorization Required

🧰 Medical Equipment and Supplies

• Diabetes supplies: Not Covered
  Prior Authorization Required
• Durable medical equipment: $25 Copay
  Prior Authorization Required
• Prosthetics: $0 - $25 Copay
  Prior Authorization Required

🔬 Diagnostics, Lab Services, and Imaging

• Diagnostic radiology services: $25 Copay
  Prior Authorization Required
• Lab services: $20 Copay
  Prior Authorization Required
• Outpatient x-rays: $0 - $65 Copay
• Diagnostic tests and procedures: $25 Copay
  Prior Authorization Required

💉 Medicare Part B Drugs

• Chemotherapy: 10% - 20% Coinsurance
  Prior Authorization Required
• Other Part B drugs (Medicare-covered): $10 Copay
  Prior Authorization Required

Supplemental Benefits

🦷 Dental Services

• Medicare Covered Preventive Dental: $2000 max
  $2000 max
• Oral exam: Not Covered
  3 visits/yr
• Dental x-rays: Not Covered
  3 visits/yr
• Cleaning: Not Covered
  1 visits/yr
• Periodontics: 30% - 40% Coinsurance
  3 visits/yr
• Endodontics: Not Covered
  2 visits/yr
• Restorative Services: 30% - 40% Coinsurance
  4 visits/yr
$2000 max
$2000 max

👂 Hearing Aids and Services

• Fitting/evaluation: Not Covered
  1 visits/yr
• Hearing aids: $399 - $699 Copay
  2 visits/yr
• Hearing exam: Not Covered
  $ max, Prior Authorization Required

👓 Vision Services

• Medicare-covered eye exam: $75 max
  $75 max, Prior Authorization Required
• Routine eye exam: Not Covered
  1 visits/yr
• Eyewear benefits: Not Covered
  1 visits/yr
Not Covered
$150/yr eyewear, Prior Authorization Required