Additional information
| Member Premium | $0 |
|---|---|
| Part B premium buy-down | $120 |
| Deductible | $0 |
| Maximum-Out-of-Pocket | $2,000 |
| Inpatient Hospital Stay | $0 copay for days 6-90, $100 copay for days 1-5 |
| Outpatient Hospitalization | $75 copay per visit |
| Doctor Visits | $0 copay per visit |
| Specialist Visits | $0 copay per visit |
| Emergency Care | $125 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 | $400 biannually ($800 annually) |
| Routine Vision and Eyewear Coverage | $0 copay, $200 annually |
| Transportation (Non-Emergency) | $0 Copay for 16 one-way trips per year, 30 mile radius |
| Flexible Health and Wellness Allowance | $90 per quarter, with rollover ($360 annually) |
| Acupuncture | $0 copay, $1,000 Max Allowance (unlimited visits) |
| Eastern Wellness Therapies | $0 copay up to 12 services per year |
| Worldwide Emergency Coverage | Up to $75,000 annual limit |
| Prescription Drug Coverage (Part D) | Included |
| Prescription Drug Deductible (Part D) | $0 |
