🩺 Doctor’s Office Visits
- Primary: $0.00 Copay
- 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 - $374.00 Copay
Prior Authorization Required - Urgent care: $30.00 Copay
- Ground ambulance: $275.00 Copay
- Inpatient hospital care: $374.00 (days 1–8), $0.00 (days 9–90)
Prior Authorization Required - Skilled Nursing Facility: $10.00 (days 1–20), $214.00 (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: 0% - 20% Coinsurance
Prior Authorization Required - Routine chiropractic: 20% Coinsurance
Prior Authorization Required
🧠 Mental Health Services
- Outpatient individual therapy: $30.00 Copay
- Outpatient group therapy: $25.00 Copay
- Inpatient psychiatric hospital care: $286.00 (days 1–8), $0.00 (days 9–90)
Prior Authorization Required
🏋️ Rehabilitation Services
- Physical therapy and speech and language therapy: $40.00 Copay
- Occupational therapy: $40.00 Copay
Prior Authorization Required
🧰 Medical Equipment and Supplies
- Diabetes supplies: $0.00 Copay
Prior Authorization Required - Durable medical equipment: $40.00 Copay
- Prosthetics: $0.00 - $40.00 Copay
🔬 Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services: $40.00 Copay
Prior Authorization Required - Lab services: $30.00 Copay
- Outpatient x-rays: 20% Coinsurance
Prior Authorization Required - Diagnostic tests and procedures: $40.00 Copay
Prior Authorization Required
💉 Medicare Part B Drugs
- Chemotherapy: 0% - 20% Coinsurance
Prior Authorization Required - Other Part B drugs (Medicare-covered): $0.00 Copay
Supplemental Benefits
🦷 Dental Services
- Medicare Covered Preventive Dental: $1650 max
$1650 max - Oral exam: $0.00 Copay
visits/yr - Dental x-rays: $0.00 Copay
visits/yr - Cleaning: $0.00 Copay
visits/yr - Periodontics: $0.00 Copay
visits/yr - Endodontics: $0.00 Copay
visits/yr - Restorative Services: $0.00 Copay
visits/yr
$1650 max
$1650 max
👂 Hearing Aids and Services
- Fitting/evaluation: Not Covered
1 visits/yr - Hearing aids: $0.00 Copay
1 visits/yr - Hearing exam: Not Covered
$ max
👓 Vision Services
- Medicare-covered eye exam: Not Covered
$ max - Routine eye exam: $0.00 Copay
visits/yr - Eyewear benefits: $0.00 Copay
visits/yr
$0.00 Copay
$215/yr eyewear