| Hospital Observation Services | $0-$150 per stay |
| Intensive Outpatient Program (IOP) | $5 |
| Home Health Services | No charge |
| Primary Care Physician Services | No charge |
| Chiropractic Services | $20 |
| Chiropractic Services | See plan details |
| Occupational Therapy Services | $50 |
| Physician Specialist Services | $55 |
| Podiatry Services | $55 |
| Other Health Care Professional Services | $0-$55 |
| Psychiatric Services | See plan details |
| Psychiatric Services — Individual Sessions | No charge |
| Psychiatric Services — Group Sessions | No charge |
| Physical Therapy & Speech-Language Pathology | $50 |
| Additional Telehealth Services (Part B) | No charge |
| Opioid Treatment Program Services | $55 |
| Diagnostic Tests & Lab Services | See plan details |
| Diagnostic Procedures & Tests | $30-$55 |
| Laboratory Services | No charge |
| Radiological Services | See plan details |
| Diagnostic Radiology | $30-$350 |
| Therapeutic Radiology | $45 |
| X-Ray Services | $30 |
| Outpatient Hospital Services | $0-$550 |
| Ambulatory Surgical Center (ASC) | $550 |
| Outpatient Substance Abuse Services | See plan details |
| Substance Abuse — Individual Sessions | No charge |
| Substance Abuse — Group Sessions | No charge |
| Dialysis Services | 20% coinsurance |
| Cardiac & Pulmonary Rehabilitation | See plan details |
| Worldwide Emergency Transportation | $400 |
| Partial Hospitalization Program | No charge |
| Worldwide Emergency Coverage | $150 |
| Skilled Nursing Facility (SNF) | $0/day for days 1–20, $221/day for days 21–100 |
| Cardiac Rehabilitation — Additional Sessions | $55 |
| Intensive Cardiac Rehabilitation — Additional Sessions | $55 |
| Pulmonary Rehabilitation — Additional Sessions | $40 |
| Supervised Exercise Therapy (SET) | $30 |
| Emergency Services | $150 |
| Urgently Needed Services | $65 |
| Worldwide Emergency & Urgent Coverage | See plan details |
| Outpatient Blood Services | No charge |
| Ambulance Services | See plan details |
| Ground Ambulance | $400 |
| Air Ambulance | $400 |
| Non-Emergency Transportation — Health Facility | No charge |
| Durable Medical Equipment (DME) | 0%-20% coinsurance |
| Prosthetics & Orthotics | See plan details |
| Prosthetic Devices | 20% coinsurance |
| Medical Supplies | 0%-20% coinsurance |
| Diabetic Supplies & Services | See plan details |
| Diabetic Supplies | No charge |
| Diabetic Therapeutic Shoes & Inserts | 20% coinsurance |
| Diabetic Monitors | No charge |
| Acupuncture | $20 |
| Other Supplemental Benefit | $260-$1,300 |
| Other Supplemental Benefit | 20% coinsurance |
| Medicare-Covered Preventive Services | See plan details |
| Annual Physical Exam | No charge |
| Health Education | No charge |
| Nutritional & Dietary Benefit | No charge |
| Fitness Benefit | No charge |
| Remote Access Technologies | No charge |
| Alternative Therapies | $20 |
| Home-Based Palliative Care | No charge |
| Kidney Disease Education Services | No charge |
| Glaucoma Screening | $55 |
| Diabetes Self-Management Training | No charge |
| Digital Rectal Exams | No charge |
| Welcome to Medicare EKG | $30 |
| Insulin (Part B) | $35 |
| Dental — Medicare-Covered Services | $55 |
| Vision — Eye Exams | $0-$35 |
| Vision — Eye Exams | See plan details |
| Vision — Routine Eye Exams | $35 |
| Vision — Eyewear | No charge |
| Hearing — Exams | $55 |
| Hearing — Exams | See plan details |
| Hearing — Routine Exams | $55 |