Additional information
| Member Premium | $15.70 |
|---|---|
| Part B premium buy-down | Not included |
| Deductible | $0 (some services and Part D drugs may have a deductible) |
| Maximum-Out-of-Pocket | $8,850 |
| Inpatient Hospital Stay** | $1,632 deductible | $0 copay for days 1-60 | $408 copay for days 61-90 |
| Outpatient Hospitalization | 20% coinsurance |
| Doctor Visits | $0 copay per visit |
| Specialist Visits | $0 copay per visit |
| Urgent Care | $25 copay per visit |
| Labs | X-ray | $0 copay | 20% coinsurance |
| Hearing Coverage | Hearing Aids | $0 copay | $600 per ear per year |
| Dental Coverage | $575 allowance per quarter |
| Routine Vision and Eyewear Coverage | $0 copay | $200 every year |
| Transportation (Non-Emergency)* | $0 copay for 48 one-way trips |
| Flexible Health and Wellness Allowance | $275 allowance every three months |
| Acupuncture | $0 copay |
| Eastern Wellness Therapies | $0 copay up to 24 services per year |
| Worldwide Emergency Coverage | Up to $100,000 annual limit |
| Prescription Drug Coverage (Part D) | Included |
| Prescription Drug Deductible (Part D)* | $545 |
