🩺 Doctor’s Office Visits

• Primary: $0.00 Copay
• Specialist: $20.00 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: % Coinsurance
  Prior Authorization Required
• Urgent care: % Coinsurance
  Prior Authorization Required
• Ground ambulance: $300.00 Copay
  Prior Authorization Required
• Inpatient hospital care: $0.00 (days –), $0.00 (days –), $0.00 (days –)
  Prior Authorization Required
• Skilled Nursing Facility: $0.00 (days 1–20), $196.00 (days 21–38), $0.00 (days 39–100)
  Prior Authorization Required

🦶 Foot Care

• Foot Exams and Treatments (Medicare-covered): 20% Coinsurance
  Prior Authorization Required
• Routine Foot Care: $0.00 - $0.00 Copay
  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: $35.00 Copay
  Prior Authorization Required
• Outpatient group therapy: $30.00 Copay
  Prior Authorization Required
• Inpatient psychiatric hospital care: $0.00 (days –), $0.00 (days –), $0.00 (days –)
  Prior Authorization Required

🏋️ Rehabilitation Services

• Physical therapy and speech and language therapy: $35.00 Copay
• Occupational therapy: $35.00 Copay
  Prior Authorization Required

🧰 Medical Equipment and Supplies

• Diabetes supplies: $0.00 Copay
  Prior Authorization Required
• Durable medical equipment: $35.00 Copay
  Prior Authorization Required
• Prosthetics: % Coinsurance
  Prior Authorization Required

🔬 Diagnostics, Lab Services, and Imaging

• Diagnostic radiology services: $35.00 Copay
  Prior Authorization Required
• Lab services: % Coinsurance
  Prior Authorization Required
• Outpatient x-rays: % Coinsurance
• Diagnostic tests and procedures: % Coinsurance
  Prior Authorization Required

💉 Medicare Part B Drugs

• Chemotherapy: $0.00 Copay
  Prior Authorization Required
• Other Part B drugs (Medicare-covered): $10.00 Copay
  Prior Authorization Required

Supplemental Benefits

🦷 Dental Services

• Medicare Covered Preventive Dental: $1,500.00 max
• Oral exam: 0% Coinsurance
• Dental x-rays: 0% Coinsurance
• Cleaning: 0% Coinsurance
• Periodontics: $25.00 Copay
• Endodontics: Not Covered
• Restorative Services: Not Covered
$1500 max

👂 Hearing Aids and Services

• Fitting/evaluation: $0.00 Copay
• Hearing aids: $0.00 Copay
• Hearing exam: $0.00 max
  Prior Authorization Required

👓 Vision Services

• Medicare-covered eye exam: $75.00 max
  Prior Authorization Required
• Routine eye exam: $0.00 Copay
• Eyewear benefits: $0.00 Copay
$150/yr eyewear