Monthly Premium
You must continue to pay your Medicare Part B premium. If you have a late enrollment penalty, it will still apply.
$165*
Max out of pocket
$4,150
Deductible
$0
Copays (PCP/Specialist)
$0/$25
Dental
$0 preventive - 2 cleanings, 2 exams, 2 fluoride treatments & a set of bite-wing x-rays per year. Full mouth x-rays are covered once every 5 years. $0 copay, no deductible, maximum benefit of $2000 per calendar year. Comprehensive dental covered 50%. Implants & dentures are not covered. PPO only network.
Over-the-counter (OTC) benefit
Vision
$0 routine exam. $150 yearly allowance for eyeglasses or contact lenses. 20% discount over $150 base allowance for frames, lenses, lens options. 40% discount applies on the purchase of any additional eyeglasses; must use EyeMed provider.
Hearing / Hearing Aids
$0 routine exam. Copays for hearing aids - 1 per ear/per year; must use NationsHearing.
Inpatient Hospital
$250 Days 1-5, $0 for Days 6-90; Unlimited days
Preventive Care
No copay for services considered preventive.
Outpatient Diagnostics Labs, Procedures, Tests
$0 lab tests. $0 - $150 copay depending on service.
Emergency Room / Urgent Care
$150/$45; worldwide coverage
Physical, Occupational and Speech Therapy
$15
Flex Card
$120 per quarter with rollover to next quarter for OTC & healthy food/produce; includes retail over-the-counter
Is Recommended
False
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Plan Documents