- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: 35% coinsurance per visit
Out-of-network: 35% coinsurance per visit
Out-of-network: 35% coinsurance
Emergency Room
$75 copay per visit (always covered)
Ambulance Coverage
In-network: $250 copay
Out-of-network: 35% coinsurance
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: In-network: $0-20 copay
Out-of-network: 35% coinsurance
Medicare-covered lab services: In-network: $0 copay
Out-of-network: 35% coinsurance
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): In-network: $0-200 copay
Out-of-network: 35% coinsurance
Medicare-covered x-ray services: In-network: $0-20 copay
Out-of-network: 35% coinsurance
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: In-network: $0-250 copay per visit
Out-of-network: 35% coinsurance per visit
Hospitalization Coverage
Inpatient hospital-acute:
In-network: $350 per stay
Out-of-network: 35% per stay
Inpatient hospital psychiatric:
In-network: $400 per day for days 1 through 3
$0 per day for days 4 through 90
Out-of-network: 35% per stay
Rehabilitation Coverage
Occupational therapy services:
In-network: $20 copay
Out-of-network: 35% coinsurance
Physical therapy and speech and language therapy services:
In-network: $20 copay
Out-of-network: 35% coinsurance
Urgent Care Coverage
$25 copay per visit (always covered)
Skilled Nursing Facility (SNF)
In-network: $0 per day for days 1 through 20
$196 per day for days 21 through 100
Out-of-network: 35% per stay
Mental Health Coverage
Medicare-covered individual sessions: In-network: $30 copay
Out-of-network: 35% coinsurance
Medicare-covered group sessions: In-network: $30 copay
Out-of-network: 35% coinsurance
Dental, Vision, Hearing Benefits
Dental Services
Oral exams: In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning): In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays: In-network: $0 copay
Out-of-network: $0 copay
Vision Benefits
Eye exams:
Routine eye exams: In-network: $0 copay
Out-of-network: 35% coinsurance
Eyewear:
Contact Lenses: Not covered
Eyeglasses: In-network: $0 copay
Out-of-network: 35% coinsurance
Hearing Benefits
Hearing exams:
Routine hearing exams: In-network: $0 copay
Out-of-network: 35% coinsurance
Hearing aids:
Hearing aids (all types): In-network: $599-899 copay
Out-of-network: 35% coinsurance
Plan Links
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