Additional information
| Member Premium | $0 |
|---|---|
| Part B premium buy-down | Not included |
| Deductible | $615 |
| Maximum-Out-of-Pocket | $9,250 |
| Inpatient Hospital Stay** | $0 copay per day for days 1–60, $1,676 deductible, $419 copay per day for days 61-90 |
| Outpatient Hospitalization | 20% coinsurance |
| Doctor Visits | $0 copay per visit |
| Specialist Visits | $0 copay per visit |
| 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 | $1,200 biannually, with rollover ($2,400 annually) |
| Routine Vision and Eyewear Coverage | $0 copay, $350 annually |
| Transportation (Non-Emergency)* | $0 copay for 48 one-way trips per year, 30 mile radius |
| Flexible Health and Wellness Allowance | $600 per quarter, with rollover ($2,400 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)* | $615 annually (does not apply to Tiers 1, 2, 6, or insulin drugs) |
