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

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45

Ground Ambulance:
Copayment for Ground Ambulance Services $295

Prior authorization may be required.

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:
Coinsurance for Medicare-covered Diabetic Supplies 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%

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

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $45
Copayment for Medicare-covered Lab Services $0 to $15
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $250
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $45

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 $2036
Prior Authorization Required for Psychiatric Hospital Services

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $40
Copayment for Medicare-covered Group Sessions $40

Prior authorization may be required.

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $280
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 $350

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $250
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 $40
Copayment for Medicare-covered Group Sessions $40
Prior Authorization Required for Outpatient Substance Abuse Services

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

• Maximum plan benefit of $20 every month for Over-The-Counter (OTC) Items

• Available through catalog purchase only
  

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $45

Medicare Covered Preventive Dental:
Copayment for Office Visit $45

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 $2,000 every year
Deductible $100.00

Eye Exams:
Copayment for Medicare Covered Benefits $45
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 $200 every year

Hearing Exams:
Copayment for Medicare Covered Benefits $45
Copayment for Routine Hearing Exams $0

• Maximum 1 visit 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

• Standard retail $1.00
• Standard mail order $1.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $2.00
• Standard mail order $2.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $2.00
• Standard mail order $2.00

• Standard retail $0.00
• Standard mail order $0.00

• Summary of benefits
• Star ratings