🩺 Doctor’s Office Visits
- Primary: Not Covered
- Specialist: $15 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 - $450 Copay
Prior Authorization Required - Urgent care: $25 Copay
Prior Authorization Required - Ground ambulance: $315 Copay
Prior Authorization Required - Inpatient hospital care: $399 (days 1–6), $0 (days 7–90)
Prior Authorization Required - Skilled Nursing Facility: $0 (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: 20% Coinsurance
Prior Authorization Required - Routine chiropractic: 20% Coinsurance
Prior Authorization Required
🧠 Mental Health Services
- Outpatient individual therapy: $25 Copay
Prior Authorization Required - Outpatient group therapy: $20 Copay
Prior Authorization Required - Inpatient psychiatric hospital care: $399 (days 1–5), $0 (days 6–90)
Prior Authorization Required
🏋️ Rehabilitation Services
- Physical therapy and speech and language therapy: $50 Copay
Prior Authorization Required - Occupational therapy: $45 Copay
Prior Authorization Required
🧰 Medical Equipment and Supplies
- Diabetes supplies: Not Covered
Prior Authorization Required - Durable medical equipment: $50 Copay
Prior Authorization Required - Prosthetics: $0 - $50 Copay
Prior Authorization Required
🔬 Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services: $45 Copay
Prior Authorization Required - Lab services: $25 Copay
Prior Authorization Required - Outpatient x-rays: $0 - $50 Copay
- Diagnostic tests and procedures: $45 - $90 Copay
Prior Authorization Required
💉 Medicare Part B Drugs
- Chemotherapy: 20% Coinsurance
Prior Authorization Required - Other Part B drugs (Medicare-covered): $10 Copay
Prior Authorization Required
Supplemental Benefits
🦷 Dental Services
- Medicare Covered Preventive Dental: Not Covered
$ max - Oral exam: Not Covered
3 visits/yr - Dental x-rays: Not Covered
3 visits/yr - Cleaning: Not Covered
1 visits/yr - Periodontics: Not Covered
- Endodontics: Not Covered
- Restorative Services: Not Covered Not Covered
$ max
👂 Hearing Aids and Services
- Fitting/evaluation: Not Covered
1 visits/yr - Hearing aids: $699 - $999 Copay
2 visits/yr - Hearing exam: Not Covered
$ max, Prior Authorization Required
👓 Vision Services
- Medicare-covered eye exam: Not Covered
$ 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