Doctor Office Visit:
Copayment for Primary Care Office Visit $0

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0
Prior Authorization Required for Acute Hospital Services

Ground Ambulance:
Copayment for Ground Ambulance Services $0

Prior Authorization Required for Ground Ambulance

Air Ambulance:
Copayment for Air Ambulance Services $0
Prior Authorization Required for Air Ambulance

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0

Durable Medical Equipment:
Copayment for Medicare-covered Durable Medical Equipment $0
Prior Authorization Required for Durable Medical Equipment

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0
Copayment for Medicare-covered Therapeutic Radiological Services $0
Copayment for Medicare-covered X-Ray Services $0

Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0
Prior Authorization Required for Psychiatric Hospital Services

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0

Prior authorization required for outpatient mental health care.

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0
Prior Authorization Required for Ambulatory Surgical Center Services

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior Authorization Required for Outpatient Substance Abuse Services

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0

Combined Group Name: OTC with OTC Hearing aids

Allowance Amount: $60.00 Every Month

Combined Benefit Groups: Over-the-Counter (OTC) Items; OTC Hearing Aids;

Mode of Delivery: Catalogue Purchase, Debit Card;

OTC items may be purchased through debit card or catalogue purchase. OTC hearing aids may be purchased through catalogue purchase. Unused allowance does not carry over to the next month.

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0

Skilled Nursing Facility Services:
Copayment for Skilled Nursing Facility Services per Stay $0
Prior Authorization Required for Skilled Nursing Facility Services

Medicare Covered Preventive Dental:
Copayment for Office Visit $0

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0

• Maximum 1 visit every six months

Copayment for Dental x-rays $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Other diagnostic services $0
Copayment for Prophylaxis $0

• Maximum 1 visit every six months

Copayment for Fluoride treatment $0

• Maximum 1 visit every six months

Copayment for Other preventive services $0

• Maximum 1 visit every six months

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Copayment for Restorative services $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Endodontics $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Periodontics $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Prosthodontics, removable $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Maxillofacial surgery $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Adjunctive general services $0
Maximum Plan Benefit of $3,000 every year

Eye Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Eye Exams $0

• Maximum 1 Routine Eye Exams every year

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
Copayment for Eyeglasses (lenses and frames) $0
Copayment for Eyeglass Lenses $0
Copayment for Eyeglass Frames $0
Maximum Plan Benefit of $300 every year

Hearing Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Hearing Exams $0

• Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0

• Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $0

• Maximum 2 Hearing Aids every year

$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

• COVID-19 shots

• Flu shots

• Hepatitis B shots

• Pneumococcal shots

Tobacco use cessation
Yearly "Wellness" visit

• Summary of benefits
• Evidence of coverage
• Star ratings