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Monthly Premium
You must continue to pay your Medicare Part B premium. If you have a late enrollment penalty, it will still apply.
$0*
Max out of pocket
$5,300
Deductible
$0
Copays (PCP/Specialist)
$0/$35. Out-of-Network: $20/$45
Dental
$0 preventive - 2 cleanings, 2 exams, 2 fluoride treatments & a set of bite-wing x-rays per year. $0 copay, no deductible, maximum benefit of $2000 per calendar year. Comprehensive dental covered 50%. Delta Dental PPO only network.
Vision
$0 routine exam. $150 yearly allowance for eyeglasses or contact lenses. 20% discount over $150 base allowance for frames, lenses, lens options. 40% discount applies on the purchase of any additional eyeglasses; must use EyeMed provider.
Hearing / Hearing Aids
$0 routine exam. Copays for hearing aids - 1 per ear/per year; must use NationsHearing.
Inpatient Hospital
$350 Days 1-5, $0 for Days 6-90. 35% coinsurance for Out-of-Network.
Preventive Care
No copay for services considered preventive.
Outpatient Diagnostics Labs, Procedures, Tests
$0 lab tests. $0 - $250 copay depending on service. 35% coinsurance for Out-of-Network.
Emergency Room / Urgent Care
$125/$45; worldwide coverage
Physical, Occupational and Speech Therapy
$20. 35% coinsurance for Out-of-Network.
Prepaid Benefits Mastercard
$105 per quarter for retail over-the-counter, dental, vision, hearing, transportation and more.
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Plan Documents