- Rx
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Emergency Room
$110 copay per visit (always covered)
Ambulance Coverage
$325 copay
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: $20 copay
Medicare-covered lab services: $20 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): 10% coinsurance
Medicare-covered x-ray services: $20 copay
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: $80-300 copay or 20% coinsurance per visit
Hospitalization Coverage
Inpatient hospital-acute:
$385 per day for days 1 through 6
$0 per day for days 7 through 90
Inpatient hospital psychiatric:
$385 per day for days 1 through 5
$0 per day for days 6 through 90
Rehabilitation Coverage
Occupational therapy services:
10% coinsurance
Physical therapy and speech and language therapy services:
10% coinsurance
Urgent Care Coverage
$25 copay per visit (always covered)
Skilled Nursing Facility (SNF)
$0 per day for days 1 through 20
$214 per day for days 21 through 100
Mental Health Coverage
Medicare-covered individual sessions: 10% coinsurance
Medicare-covered group sessions: 10% coinsurance
Dental, Vision, Hearing Benefits
Vision Benefits
Eye exams:
Routine eye exams: Not covered
Eyewear:
Contact Lenses: Not covered
Eyeglasses: Not covered
Hearing Benefits
Hearing exams:
Routine hearing exams: $45 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$9.00 copay (30-day supply)
$18.00 copay (90-day supply)
Tier 2: Generic
$18.00 copay (30-day supply)
$36.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$94.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$100.00 copay (30-day supply)
$200.00 copay (90-day supply)
Tier 5: Specialty Tier
30% coinsurance (30-day supply)
More Additional Benefits
Plan Links
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