Doctor Office Visit:
Copayment for Primary Care Office Visit $5

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $50

Urgent Care:
Copayment for Urgent Care $50

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0
Maximum Plan Benefit of $50,000

Ground Ambulance:
Copayment for Ground Ambulance Services $325

Prior authorization may be required

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

Medicare Covered Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 40%

Medicare Covered Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 40%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 40%

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 $25
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 $275
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $45

Prior Authorization Required for Pulmonary Rehabilitation Services

Medicare Covered Home Health Services:
Coinsurance for Medicare Covered Home Health 40%

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $2290
Prior Authorization Required for Psychiatric Hospital Services
190-day limitation is combined for In-Network and Out-of-Network services

Medicare Covered Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 40%
Coinsurance for Medicare Covered Group Sessions 40%

Prior authorization may be required.

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $325
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 $325

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $200
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 $50 every three months for Over-The-Counter (OTC) Items

• Available through catalog purchase only
  

Medicare Covered Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 40%

Skilled Nursing Facility Services:
Coinsurance for Skilled Nursing Facility per Stay 40%

Medicare Covered Preventive Dental:
Copayment for Office Visit $50

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

Eye Exams:
Copayment for Medicare Covered Benefits $50
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 $50
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