Additional information
| Member Premium | $0 |
|---|---|
| Part B premium buy-down | Not included |
| Deductible | $0 |
| Maximum-Out-of-Pocket | $500 |
| 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 | $90 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 | $1,100 every six months with rollover ($2,200 annually) |
| Routine Vision and Eyewear Coverage | $300 every year, $0 copay |
| Transportation (Non-Emergency)* | $0 copay | 48 trips per year (one-way) |
| Flexible Health and Wellness Allowance | $315 per quarter, with rollover ($1,260 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)* | $0 |
