Additional information
| Member Premium | $0 |
|---|---|
| Part B premium buy-down | Not included |
| Deductible | $0 |
| Maximum-Out-of-Pocket | $1,700 |
| Inpatient Hospital Stay** | $0 copay unlimited days |
| Outpatient Hospitalization | $0 copay per visit |
| Doctor Visits | $0 copay per visit |
| Specialist Visits | $0 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 | $600 allowance per quarter |
| Routine Vision and Eyewear Coverage | $0 copay | $200 every year |
| Transportation (Non-Emergency)* | $0 copay for 24 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 $75,000 annual limit |
| Prescription Drug Coverage (Part D) | Included |
| Prescription Drug Deductible (Part D)* | $0 |
