🩺 Doctor’s Office Visits

Service	{plan_year}	{prev_plan_year}
Primary	{in_primary}	$0.00 Copay Referral Required
Specialist	{in_specialist}	$20.00 Copay Prior Authorization Required, Referral Required

🏥 Emergency, Urgent, and Inpatient Hospital Coverage

Service	{plan_year}	{prev_plan_year}
Emergency room care	{emergency_room}	$0.00 Copay Prior Authorization Required, Referral Required
Urgent care	{urgent_care}	$0.00 Copay Prior Authorization Required, Referral Required
Ground ambulance	{ground_ambulance}	$275.00 Copay Prior Authorization Required, Referral Required
Inpatient hospital care	{inpatient_hospital}	$495.00 (days 1–5), $0.00 (days 6–90), $0.00 (days –) Prior Authorization Required, Referral Required
Skilled Nursing Facility	{snf_stay}	$0.00 (days 1–20), $203.00 (days 21–100), $0.00 (days –) Prior Authorization Required, Referral Required

🦶 Foot Care

Service	{plan_year}	{prev_plan_year}
Foot Exams and Treatments (Medicare-covered)	{in_foot_exams}	$0.00 Copay Prior Authorization Required, Referral Required
Routine Foot Care	{in_routine_foot_care}	$0.00 Copay Prior Authorization Required, Referral Required

💆 Chiropractic Care

Service	{plan_year}	{prev_plan_year}
Medicare-covered chiropractic	{in_mc_chiropractic}	$0.00 Copay Prior Authorization Required, Referral Required
Routine chiropractic	{in_routine_chiropractic}	$0.00 Copay Prior Authorization Required, Referral Required

🧠 Mental Health Services

Service	{plan_year}	{prev_plan_year}
Outpatient individual therapy	{in_psych_outpatient_indiv}	$0.00 Copay Prior Authorization Required, Referral Required
Outpatient group therapy	{in_psych_outpatient_group}	$0.00 Copay Prior Authorization Required, Referral Required
Inpatient psychiatric hospital care	{in_psych_inpatient_hospital}	$495.00 (days 1–4), $0.00 (days 5–90), $0.00 (days –) Prior Authorization Required, Referral Required

🏋️ Rehabilitation Services

Service	{plan_year}	{prev_plan_year}
Physical therapy and speech/language therapy	{in_phy_speech_therapy}	$0.00 Copay Prior Authorization Required, Referral Required
Occupational therapy	{in_occ_therapy}	$0.00 Copay Prior Authorization Required, Referral Required

🧰 Medical Equipment and Supplies

Service	{plan_year}	{prev_plan_year}
Diabetes supplies	{in_diabetes_supplies}	$0.00 Copay Prior Authorization Required, Referral Required
Durable medical equipment	{in_dme}	$45.00 Copay Prior Authorization Required, Referral Required
Prosthetics	{in_prosthetics}	$0.00 Copay Prior Authorization Required, Referral Required

🔬 Diagnostics, Lab Services, and Imaging

Service	{plan_year}	{prev_plan_year}
Diagnostic radiology services	{in_diagnostic_radiology}	$0.00 Copay Prior Authorization Required, Referral Required
Lab services	{in_lab_services}	$0.00 Copay Prior Authorization Required, Referral Required
Outpatient x-rays	{in_outpatient_xrays}	$0.00 Copay Referral Required
Diagnostic tests and procedures	{in_diag_tests_procedures}	$0.00 Copay Prior Authorization Required, Referral Required

💉 Medicare Part B Drugs

Service	{plan_year}	{prev_plan_year}
Chemotherapy	{in_part_b_chemo}	$0.00 Copay Prior Authorization Required, Referral Required
Other Part B drugs (Medicare-covered)	{in_other_part_b_drugs}	$0.00 Copay Prior Authorization Required, Referral Required

Supplemental Benefits

🦷 Dental Services

Service	{plan_year}	{prev_plan_year}
Medicare Covered Preventive Dental	{in_mc_dent_preventive}	$0.00 max $0.00 max Referral Required
Oral exam	{in_dent_oral_exam}	$0.00 Copay Referral Required
Dental x-rays	{in_dent_xrays}	$0.00 Copay Referral Required
Cleaning	{in_dent_cleaning}	Not Covered Referral Required
Periodontics	{in_dent_periodontics}	Not Covered Referral Required
Endodontics	{in_dent_endodontics}	Not Covered Referral Required
Restorative Services	{in_dent_restorative}	Not Covered Referral Required
Dental Maximum	{dental_maximum}	Not Covered

👂 Hearing Aids and Services

Service	{plan_year}	{prev_plan_year}
Fitting/evaluation	{in_hearing_aid_fit_eval}	$0.00 Copay Referral Required
Hearing aids	{in_hearing_aids}	Not Covered Referral Required
Hearing exam	{in_hearing_exam}	$0.00 max $0.00 max Prior Authorization Required, Referral Required
Hearing Maximum	{hearing_maximum}	$0.00 max

👓 Vision Services

Service	{plan_year}	{prev_plan_year}
Medicare-covered eye exam	{in_vision_mc_exam}	$0.00 max $0.00 max Prior Authorization Required, Referral Required
Routine eye exam	{in_vision_routine_exam}	$0.00 Copay Referral Required
Eyewear benefits	{vision_eyewear_benefits}	Not Covered Referral Required
Vision Eyewear Maximum	{vision_eyewear_maximum}	$300.00/yr eyewear