| Emergency Services | $130 |
| Radiological Services | See plan details |
| Hearing — Exams | See plan details |
| Dental — Comprehensive | See plan details |
| Vision — Eye Exams | See plan details |
| Urgently Needed Services | $50 |
| Worldwide Emergency & Urgent Coverage | See plan details |
| Worldwide Emergency Coverage | $130 |
| Worldwide Emergency Transportation | $325 |
| X-Ray Services | $0-$125 |
| Partial Hospitalization Program | $35 |
| Skilled Nursing Facility (SNF) | $0/day for days 1–20, $218/day for days 21–100 |
| Cardiac & Pulmonary Rehabilitation | See plan details |
| Cardiac Rehabilitation — Additional Sessions | $20 |
| Intensive Cardiac Rehabilitation — Additional Sessions | $20 |
| Pulmonary Rehabilitation — Additional Sessions | $20 |
| Supervised Exercise Therapy (SET) | $20 |
| Intensive Outpatient Program (IOP) | $35 |
| Home Health Services | No charge |
| Primary Care Physician Services | No charge |
| Chiropractic Services | $15 |
| Chiropractic Services | See plan details |
| Occupational Therapy Services | $20 |
| Physician Specialist Services | $20 |
| Podiatry Services | $20 |
| Podiatry Services | No charge |
| Other Health Care Professional Services | $0-$20 |
| Psychiatric Services | See plan details |
| Psychiatric Services — Individual Sessions | $25 |
| Psychiatric Services — Group Sessions | $25 |
| Physical Therapy & Speech-Language Pathology | $20 |
| Additional Telehealth Services (Part B) | $0-$50 |
| Opioid Treatment Program Services | $25-$35 |
| Diagnostic Tests & Lab Services | See plan details |
| Diagnostic Procedures & Tests | $0-$80 |
| Laboratory Services | No charge |
| Diagnostic Radiology | $0-$335 |
| Therapeutic Radiology | $20 copay + 20% coinsurance |
| Outpatient Hospital Services | $0-$180 |
| Hospital Observation Services | $455 per stay |
| Ambulatory Surgical Center (ASC) | $0-$105 |
| Outpatient Substance Abuse Services | See plan details |
| Substance Abuse — Individual Sessions | $25-$35 |
| Substance Abuse — Group Sessions | $25-$35 |
| Outpatient Blood Services | No charge |
| Ambulance Services | See plan details |
| Ground Ambulance | $325 |
| Air Ambulance | 20% coinsurance |
| Non-Emergency Transportation — Health Facility | No charge |
| Durable Medical Equipment (DME) | 20% coinsurance |
| Prosthetics & Orthotics | See plan details |
| Prosthetic Devices | 20% coinsurance |
| Medical Supplies | 20% coinsurance |
| Diabetic Supplies & Services | See plan details |
| Diabetic Supplies | 20% coinsurance |
| Diabetic Therapeutic Shoes & Inserts | $10 |
| Diabetic Monitors | 20% coinsurance |
| Dialysis Services | 20% coinsurance |
| Acupuncture | No charge |
| Over-the-Counter (OTC) Items | No charge |
| Meal Benefit | No charge |
| Medicare-Covered Preventive Services | See plan details |
| Welcome to Medicare EKG | No charge |
| Annual Physical Exam | No charge |
| Fitness Benefit | No charge |
| In-Home Support Services | No charge |
| Kidney Disease Education Services | No charge |
| Glaucoma Screening | No charge |
| Diabetes Self-Management Training | No charge |
| Digital Rectal Exams | No charge |
| Insulin (Part B) | 0%-20% coinsurance (max $35) |
| Dental — Medicare-Covered Services | $20 |
| Dental — Preventive | See plan details |
| Dental — Oral Exams | No charge |
| Dental — X-Rays | No charge |
| Dental — Prophylaxis (Cleaning) | No charge |
| Dental — Restorative Services | No charge |
| Dental — Endodontics (Root Canal) | No charge |
| Dental — Periodontics (Gum Care) | No charge |
| Dental — Fixed Prosthodontics (Bridges) | No charge |
| Dental — Oral & Maxillofacial Surgery | No charge |
| Dental — Adjunctive General Services | No charge |
| Vision — Eye Exams | $0-$20 |
| Vision — Routine Eye Exams | No charge |
| Vision — Eyewear | No charge |
| Vision — Eyewear | See plan details |
| Vision — Contact Lenses | No charge |
| Vision — Eyeglasses (Lenses & Frames) | No charge |
| Hearing — Exams | $20 |
| Hearing — Routine Exams | No charge |
| Hearing — Fitting & Evaluation for Hearing Aid | No charge |
| Hearing — Prescription Hearing Aids | See plan details |
| Hearing — Hearing Aids (All Types) | No charge |
| Hearing — OTC Hearing Aids | No charge |