Covered Services |
What You Pay |
Physician Services/Doctor Office Visits |
PCP - $0 |
Specialist $25 |
Annual Wellness Visit |
$0 |
Telehealth Benefit |
E-Visit PCP - $0 |
E-Visit Specialist - $15 |
Video Visit PCP - $0 |
Video Visit Specialist - $15 |
Preventive Health Screenings |
$0 |
Inpatient Hospital Care |
$300 per admission |
No limit to the number of days covered |
Skilled Nursing Facility (SNF) |
$0/Day - Days 1-20 |
$100/ Day - Days 21-100 |
Outpatient Diagnostic Tests and Therapeutic Services & Supplies |
Diagnostic labs & x-rays - $0 |
Cardiac Stress Test - $25 |
Advanced Radiology - $100 |
MRI - $100 |
PET Scan - $100 |
Radiation Therapy, IMRT - $15 |
Emergency Care |
$120 |
Ambulance Services |
$100 |
Urgently Needed Services |
$25 |
Outpatient Hospital Observation |
$175 |
Outpatient Hospital Services |
ASC - $150 |
Hospital $175 |
Outpatient Surgery |
ASC - $150 |
Hospital $175 |
Outpatient Rehab Services |
PT and OT - $15 |
Speech - $15 |
Would Care/Lymphedema - $15 |
Outpatient Mental Health Care |
Individual or Group - $20 |
Outpatient Substance Abuse Services |
Individual or Group - 20 |
Durable Medical Equipment (DME) and related Supplies |
20% meters, test strips, lancets, lancet devices and control solutions |
All other DME is 10% coinsurance |
Prosthetic Devices and Related Supplies |
20% coinsurance |
Medicare Part B Prescription Drugs |
15% coinsurance (including chemotherapy) |
Services to Treat Kidney Disease |
20% coinsurance |
$0 for education services |
Pulmonary Rehabilitation Services |
$15 |
Cardiac Rehabilitation Services |
$15 |
Chiropractic Services |
$15 |
Acupuncture |
$20 |
Podiatry Services |
$15 |
Home Health Agency Care |
$0 |
Inpatient Mental Health Care |
$300 per admission |
Medical Nutrition Therapy |
$0 |
Dental Services |
$0 - Medicare Covered |
Diabetes Self Management Training, Diabetic Services and Supplies |
20% for diabetic shoes & inserts |
10% for insulin pump & supplies |
Immunizations |
$0 |
Transportation |
$0 (20 one-way trips per year) |
Smoking Cessation |
$0 |
Hearing Services |
Diagnostic - $15 |
Routine - $0 |
Hearing Aid Fitting - $15 |
Vision Care |
Diagnostic - $0 |
Routine - $0 |
$200 plan allowance per year |