🩺 Doctor’s Office Visits

• Primary: Not Covered
• Specialist: $20.00 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 - $325.00 Copay
• Urgent care: $25.00 Copay
• Ground ambulance: $300.00 Copay
• Inpatient hospital care: $318.00 (days 1–5), $0.00 (days 6–90)
• Skilled Nursing Facility: $0.00 (days 1–20), $214.00 (days 21–100)

🦶 Foot Care

• Foot Exams and Treatments (Medicare-covered): 20% Coinsurance
• Routine Foot Care: 0% - 20% Coinsurance

💆 Chiropractic Care

• Medicare-covered chiropractic: 0% - 15% Coinsurance
• Routine chiropractic: 15% Coinsurance

🧠 Mental Health Services

• Outpatient individual therapy: $20.00 Copay
• Outpatient group therapy: $10.00 Copay
• Inpatient psychiatric hospital care: $318.00 (days 1–5), $0.00 (days 6–90)

🏋️ 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
• Durable medical equipment: Not Covered
  6 visits/yr
• Prosthetics: $0.00 - $25.00 Copay

🔬 Diagnostics, Lab Services, and Imaging

• Diagnostic radiology services: $25.00 Copay
• Lab services: $25.00 Copay
• Outpatient x-rays: Not Covered
• Diagnostic tests and procedures: $25.00 Copay

💉 Medicare Part B Drugs

• Chemotherapy: Not Covered
• Other Part B drugs (Medicare-covered): $10.00 Copay

Supplemental Benefits

🦷 Dental Services

• Medicare Covered Preventive Dental: $4500.00 max
• Oral exam: Not Covered
• Dental x-rays: Not Covered
• Cleaning: Not Covered
• Periodontics: $20.00 Copay
• Endodontics: $20.00 Copay
• Restorative Services: $20.00 Copay
$4500.00 max

👂 Hearing Aids and Services

• Fitting/evaluation: Not Covered
• Hearing aids: $395.00 - $1595.00 Copay
• Hearing exam: Not Covered

👓 Vision Services

• Medicare-covered eye exam: Not Covered
• Routine eye exam: Not Covered
• Eyewear benefits: Not Covered
$300.00/yr eyewear