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

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $10

Ground Ambulance:
Copayment for Ground Ambulance Services $50

Prior authorization required for Ground Ambulance Services

Air Ambulance:
Coinsurance for Air Ambulance Services 20%
Prior Authorization Required for Air Ambulance

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15

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

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
Minimum coinsurance applies to all other DME. A 10% coinsurance applies to HIT drug component services provided in the home. Maximum coinsurance applies to HIT drug component services provided in all other locations.

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $25
Copayment for Medicare-covered Lab Services $0 to $10
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $175
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $15

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 $2290
Prior Authorization Required for Psychiatric Hospital Services

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $10
Copayment for Medicare-covered Group Sessions $10

Prior authorization required for Outpatient Mental Health Care.

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $200
Prior Authorization Required for Outpatient Hospital Services
Minimum amount for diagnostic colonoscopies in an outpatient setting. Maximum amount for all other services.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $200

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $100
Prior Authorization Required for Ambulatory Surgical Center Services
Minimum amount for diagnostic colonoscopies in an ASC setting. Maximum amount for all other services.

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $10
Copayment for Medicare-covered Group Sessions $10
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: $50.00 Every Month

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

Mode of Delivery: Catalogue Purchase; Unused allowance does not carry over to the next month.

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $10

Medicare Covered Preventive Dental:
Copayment for Office Visit $10

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
Coinsurance for Restorative services 20% to 50%

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

Coinsurance for Endodontics 50%

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

Coinsurance for Periodontics 50%

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

Coinsurance for Prosthodontics, removable 50%

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

Coinsurance for Maxillofacial surgery 50%

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

Copayment for Adjunctive general services $0
Maximum Plan Benefit of $3,000 every year
Deductible $100.00

Eye Exams:
Copayment for Medicare Covered Benefits $10
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 $550 every year

Hearing Exams:
Copayment for Medicare Covered Benefits $10
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 three years

Maximum Plan Benefit of $3,000 every three years

$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
• Star ratings