Additional information
| Plan Premium | $33.20 |
|---|---|
| Medical Deductible (Part A) | $0 |
| Prescription Drug Deductible (Part D) | $480 |
| Maximum-Out-of-Pocket | $5,999 |
| Prescription Drugs (Part D) | Included* |
| Doctor Visits | $0 copay |
| Hospital Stay | $0 copay for days 1-60 | $371 copy for days 61-90 |
| Transportation (Non-Emergency) | $0 copay | 48 trips per year (one-way) |
| Flexible Health and Wellness Allowance | $300 allowance every three months |
| Labs/X-ray | 20% Coinsurance |
| Dental Coverage | Up to $2,500 per year |
| Routine Vision and Eyewear Coverage | $0 copay | $300 every year |
| Hearing Coverage | $0 copay | $1,500 per ear every year |
| Acupuncture | $0 copay |
| Eastern Wellness Therapies | $0 copay up to 24 services per year |
