Additional information
| Member Premium | $18.40 |
|---|---|
| Part B premium buy-down | Not included |
| Deductible | $0 |
| Maximum-Out-of-Pocket | $9,350 |
| Inpatient Hospital Stay** | $0 copay per day for days 1–60, $1,632 deductible, $408 copay per day for days 61–90 |
| Outpatient Hospitalization | 20% coinsurance |
| Doctor Visits | 20% Coinsurance |
| Specialist Visits | 20% Coinsurance |
| Emergency Care | $95 copay per visit |
| Urgent Care | $25 copay per visit |
| Labs | X-ray | 20% Coinsurance |
| Hearing Coverage | Hearing Aids | $0 Copay, $600 per ear, per year |
| Dental Coverage | $550 per quarter, with rollover ($2,200 annually) |
| Routine Vision and Eyewear Coverage | $0 copay, $200 annually |
| Transportation (Non-Emergency)* | $0 copay for 24 one-way trips per year, 30 mile radius |
| Flexible Health and Wellness Allowance | $200 per quarter, no rollover ($800 annually) |
| Acupuncture | $0 copay, $2,000 Max Allowance (unlimited visits) |
| 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)* | $590 |
