Monthly Premium
You must continue to pay your Medicare Part B premium. If you have a late enrollment penalty, it will still apply.
$0*
Max out of pocket
$4,500
Deductible
$0
Copays (PCP/Specialist)
$0/$40
Dental
$0 preventive - 2 cleanings; 2 exams & a set of bite-wing x-rays; 50% coinsurance for comprehensive services with $3,000 max benefit allowance.
Over-the-counter (OTC) benefit
$75 allowance/quarter and can rollover
Vision
$0 routine exam. $130 yearly allowance for eyeglasses or contact lenses.
Hearing / Hearing Aids
$0 routine exam. Copays for hearing aids - 1 per ear/per year.
Inpatient Hospital
$310/day for days 1-6; $0/day for Days 7-90
Preventive Care
No copay for services considered preventive.
Outpatient Diagnostic Labs, Procedures, Tests
$0 - $150 depending on service.
Emergency Room / Urgent Care
$90/$55 no limit; worldwide coverage
Physical, Occupational and Speech Therapy
$20 per visit; unlimited
Flex Card
Not applicable
Transportation
Is Recommended
False