🩺 Doctor’s Office Visits

• Primary: $0.00 Copay
  Referral Required
• Specialist: $20.00 Copay
  Prior Authorization Required, Referral 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: $0.00 - $245.00 Copay
  Prior Authorization Required, Referral Required
• Urgent care: $0.00 - $25.00 Copay
  Prior Authorization Required, Referral Required
• Ground ambulance: $275.00 Copay
  Prior Authorization Required, Referral Required
• Inpatient hospital care: Not Covered
  Prior Authorization Required, Referral Required
• Skilled Nursing Facility: $0.00 (days 1–20), $203.00 (days 21–100)
  Prior Authorization Required, Referral Required

🦶 Foot Care

• Foot Exams and Treatments (Medicare-covered): 20% Coinsurance
  Prior Authorization Required, Referral Required
• Routine Foot Care: 0% - 20% Coinsurance
  Prior Authorization Required, Referral Required

💆 Chiropractic Care

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

🧠 Mental Health Services

• Outpatient individual therapy: $0.00 Copay
  Prior Authorization Required, Referral Required
• Outpatient group therapy: $0.00 Copay
  Prior Authorization Required, Referral Required
• Inpatient psychiatric hospital care: Not Covered
  Prior Authorization Required, Referral Required

🏋️ Rehabilitation Services

• Physical therapy and speech and language therapy: $0.00 - $25.00 Copay
  Prior Authorization Required, Referral Required
• Occupational therapy: $0.00 - $25.00 Copay
  Prior Authorization Required, Referral Required

🧰 Medical Equipment and Supplies

• Diabetes supplies: $0.00 Copay
  Prior Authorization Required, Referral Required
• Durable medical equipment: $25.00 Copay
  6 visits/yr, Prior Authorization Required, Referral Required
• Prosthetics: $0.00 - $25.00 Copay
  Prior Authorization Required, Referral Required

🔬 Diagnostics, Lab Services, and Imaging

• Diagnostic radiology services: $0.00 - $25.00 Copay
  Prior Authorization Required, Referral Required
• Lab services: $0.00 - $25.00 Copay
  Prior Authorization Required, Referral Required
• Outpatient x-rays: $0.00 Copay
  Referral Required
• Diagnostic tests and procedures: $0.00 Copay
  Prior Authorization Required, Referral Required

💉 Medicare Part B Drugs

• Chemotherapy: $0.00 Copay
  Prior Authorization Required, Referral Required
• Other Part B drugs (Medicare-covered): 20% Coinsurance
  Prior Authorization Required, Referral Required

Supplemental Benefits

🦷 Dental Services

• Medicare Covered Preventive Dental: $500.00 max
  $500.00 max, Referral Required
• Oral exam: $0.00 Copay
  1 visits/yr, Referral Required
• Dental x-rays: $0.00 Copay
  1 visits/yr, Referral Required
• Cleaning: $0.00 Copay
  1 visits/yr, Referral Required
• Periodontics: $0.00 Copay
  1 visits/yr, Referral Required
• Endodontics: $0.00 Copay
  1 visits/yr, Referral Required
• Restorative Services: 0% - 50% Coinsurance
  1 visits/yr, Referral Required
$500.00 max
$500.00 max, Referral Required

👂 Hearing Aids and Services

• Fitting/evaluation: $0.00 Copay
  1 visits/yr, Referral Required
• Hearing aids: Not Covered
  Referral Required
• Hearing exam: Not Covered
  $ max, Prior Authorization Required, Referral Required

👓 Vision Services

• Medicare-covered eye exam: Not Covered
  $ max, Prior Authorization Required, Referral Required
• Routine eye exam: $0.00 Copay
  visits/yr, Referral Required
• Eyewear benefits: Not Covered
  Referral Required
$0.00 Copay
$200.00/yr eyewear, Referral Required