Coverage Details
Medical | |
---|---|
Medical Deductible | This plan does not have any medical deductibles. |
Primary Care Provider Visit | $0 copay |
Specialist Visit | $50 copay |
Referrals | Required for Specialist Visits only |
Urgent Care | $40 copay |
Telemedicine | $0 copay |
Ambulatory Surgical Centers Outpatient Surgery | $250 copay |
Emergency Care | $95 copay |
Worldwide Emergency & Urgently Needed Services | Not covered |
Inpatient Hospital Stay | $350/day copay for days 1-5; $0 copay for days 6-90; Medicare allows 60 "lifetime reserve" days |
Routine Podiatry Services | Medicare-covered podiatry care: Non-Medicare covered podiatry care: |
Acupuncture | Medicare-covered acupuncture: |
Routine Chiropractic Services | Medicare-covered chiropractic care: $10 copay Non-Medicare covered chiropractic care: Not covered |
Hearing Aid Services | $0 copay (hearing exam) |
Silver&Fit® Program | You pay nothing at participating fitness centers. |
Prescription | |
Pharmacy Deductible | Part D benefits are not offered with this plan. |
Mail Order | Part D benefits are not offered with this plan. |
Preferred Generic (Tier 1) | Part D benefits are not offered with this plan. |
Generic (Tier 2) | Part D benefits are not offered with this plan. |
Preferred Brand (Tier 3) | Part D benefits are not offered with this plan. |
Non-Preferred Drug (Tier 4) | Part D benefits are not offered with this plan. |
Specialty Tier (Tier 5) | Part D benefits are not offered with this plan. |
Vision | |
Medicare-covered exam to diagnose and treat diseases and conditions of the eye | $50 copay |
Yearly Glaucoma Screening | You pay nothing |
Routine Eye Exam | (1 every year): |
Eyeglasses or Contact Lenses after Cataract Surgery | You pay nothing |
Routine Eyewear | Our plan pays up to $300 every two years for supplemental eyewear (retail or online) from any provider. |
Dental | |
Medicare-covered Dental Services | You pay nothing |
Preventive Dental Services | You pay nothing |
Fluoride Treatments | You pay nothing |
Comprehensive Dental Services | (Frequency dependent on procedure.) |
Optional Supplemental Benefits | Not available |
Restorative services (such as inlays, onlays, crowns, resin restoration, etc.) | Frequency dependent on procedure. |
Endodontics | Frequency dependent on procedure. |
Periodontics | Frequency dependent on procedure. |
Extractions | Frequency dependent on procedure. |
Prosthodontics/Other oral/maxillofacial surgery/Other services (such as removable complete and partial dentures, repair or replace teeth in dentures, removal of exostosis, anesthesia, etc.) | Frequency dependent on procedure. |