Additional information
| Plan Premium | $0 |
|---|---|
| Part B premium buy-down | The difference between the $125, paid by the plan, and the CY2022 Part B Premium. |
| Medical Deductible (Part A) | $0 |
| Prescription Drug Deductible (Part D) | $0 |
| Maximum-Out-of-Pocket | $3,000 |
| Prescription Drugs (Part D) | Included* |
| Doctor Visits | $0 copay |
| Hospital Stay | $75 copay for days 1-5 | $0 copay for days 6 and more |
| Transportation (Non-Emergency) | $0 copay | 24 trips per year (one-way) |
| Flexible Health and Wellness Allowance | $60 allowance every three months |
| Labs/X-ray | $0 copay |
| Dental Coverage | Up to $500 per year |
| Routine Vision and Eyewear Coverage | $0 copay | $320 every two years |
| Hearing Coverage | $0 copay | $500 per ear every year |
| Acupuncture | $0 copay up to 24 visits per year |
| Eastern Wellness Therapies | $0 copay up to 12 services per year |
