| Dental — Comprehensive | See plan details |
| Vision — Eyeglasses (Lenses & Frames) | No charge |
| Vision — Eyeglass Lenses | No charge |
| Vision — Eyeglass Frames | No charge |
| Diabetic Therapeutic Shoes & Inserts | No charge |
| Skilled Nursing Facility (SNF) | See plan details |
| Cardiac & Pulmonary Rehabilitation | See plan details |
| Cardiac Rehabilitation — Additional Sessions | $30 |
| Intensive Cardiac Rehabilitation — Additional Sessions | $35 |
| Pulmonary Rehabilitation — Additional Sessions | $25 |
| Supervised Exercise Therapy (SET) | $20 |
| Emergency Services | $115 |
| Vision — Contact Lenses | No charge |
| Urgently Needed Services | $40 |
| Worldwide Emergency & Urgent Coverage | See plan details |
| Worldwide Emergency Coverage | $115 |
| Worldwide Emergency Transportation | $275 |
| Partial Hospitalization Program | $55 |
| Intensive Outpatient Program (IOP) | $55 |
| Home Health Services | No charge |
| Primary Care Physician Services | $10 |
| Chiropractic Services | No charge |
| Occupational Therapy Services | $35 |
| Physician Specialist Services | $0-$40 |
| Podiatry Services | $40 |
| Other Health Care Professional Services | $0-$40 |
| Psychiatric Services | See plan details |
| Psychiatric Services — Individual Sessions | $40 |
| Psychiatric Services — Group Sessions | $20 |
| Physical Therapy & Speech-Language Pathology | $35 |
| Additional Telehealth Services (Part B) | No charge |
| Opioid Treatment Program Services | $40 |
| Diagnostic Tests & Lab Services | See plan details |
| Diagnostic Procedures & Tests | $0-$35 |
| Laboratory Services | $0-$35 |
| Radiological Services | See plan details |
| Diagnostic Radiology | $10-$340 |
| Therapeutic Radiology | $40 |
| X-Ray Services | $10-$50 |
| Outpatient Hospital Services | $0-$275 |
| Hospital Observation Services | $0-$275 |
| Ambulatory Surgical Center (ASC) | $275 |
| Outpatient Substance Abuse Services | See plan details |
| Substance Abuse — Individual Sessions | $40 |
| Substance Abuse — Group Sessions | $20 |
| Outpatient Blood Services | No charge |
| Ambulance Services | See plan details |
| Ground Ambulance | $275 |
| Air Ambulance | $275 |
| Non-Emergency Transportation — Health Facility | $0-$125 |
| Durable Medical Equipment (DME) | No charge |
| Prosthetics & Orthotics | See plan details |
| Prosthetic Devices | No charge |
| Medical Supplies | No charge |
| Diabetic Supplies & Services | See plan details |
| Diabetic Monitoring Supplies | No charge |
| Dialysis Services | No charge |
| Over-the-Counter (OTC) Items | No charge |
| Other Supplemental Benefit | $395-$1975 |
| Other Supplemental Benefit | No charge |
| Medicare-Covered Preventive Services | See plan details |
| Annual Physical Exam | No charge |
| Health Education | No charge |
| Fitness Benefit | No charge |
| Remote Access Technologies | No charge |
| Kidney Disease Education Services | No charge |
| Glaucoma Screening | No charge |
| Diabetes Self-Management Training | No charge |
| Digital Rectal Exams | No charge |
| Welcome to Medicare EKG | No charge |
| Insulin (Part B) | $0-$35 |
| Dental — Medicare-Covered Services | $40 |
| Dental — Preventive | No charge |
| Dental — Oral Exams | No charge |
| Dental — X-Rays | No charge |
| Dental — Diagnostic Services | No charge |
| Dental — Prophylaxis (Cleaning) | No charge |
| Dental — Fluoride Treatment | No charge |
| Dental — Other Preventive Services | No charge |
| Dental — Restorative Services | $18-$464 |
| Dental — Endodontics (Root Canal) | $22-$625 |
| Dental — Periodontics (Gum Care) | $0-$643 |
| Dental — Removable Prosthodontics (Dentures) | $25-$738 |
| Dental — Fixed Prosthodontics (Bridges) | $44-$528 |
| Dental — Oral & Maxillofacial Surgery | $0-$490 |
| Dental — Adjunctive General Services | $0-$151 |
| Vision — Eye Exams | $0-$40 |
| Vision — Eye Exams | See plan details |
| Vision — Routine Eye Exams | No charge |
| Vision — Eyewear | No charge |
| Vision — Eyewear | See plan details |
| Hearing — Exams | $40 |
| Hearing — Exams | See plan details |
| Hearing — Routine Exams | No charge |