Additional information
| Member Premium | $0 |
|---|---|
| Part B premium buy-down | $50 paid by the plan |
| Deductible | $0 |
| Maximum-Out-of-Pocket | $2,500 |
| Inpatient Hospital Stay | $100 copay per day for days 1–5 | $0 copay per day for days 6–90 |
| Outpatient Hospitalization | $0 copay per visit |
| Doctor Visits | $0 copay per visit |
| Specialist Visits | $5 copay per visit |
| Emergency Care | $75 copay per visit |
| Urgent Care | $0 copay per visit |
| Labs | X-ray | $0 copay |
| Hearing Coverage | Hearing Aids | $0 copay | $600 per ear per year |
| Dental Coverage | $300 allowance per quarter |
| Routine Vision and Eyewear Coverage | $0 copay | $200 every year |
| Transportation (Non-Emergency) | $0 copay for 16 one-way trips |
| Flexible Health and Wellness Allowance | $250 for fitness, $75 for OTC & Herbal supplements every three months |
| Acupuncture | $0 copay |
| Eastern Wellness Therapies | $0 copay up to 18 services per year |
| Worldwide Emergency Coverage | Up to $100,000 annual limit |
| Prescription Drug Coverage (Part D) | Included* |
| Prescription Drug Deductible (Part D) | $0 |
