| Diagnostic Tests & Lab Services | See plan details |
| Diagnostic Procedures & Tests | 20% coinsurance |
| Laboratory Services | No charge |
| X-Ray Services | 20% coinsurance |
| Outpatient Hospital Services | 0%-20% coinsurance |
| Hospital Observation Services | 20% coinsurance |
| Outpatient Substance Abuse Services | See plan details |
| Substance Abuse — Individual Sessions | 20% coinsurance |
| Outpatient Blood Services | 20% coinsurance |
| Ambulance Services | See plan details |
| Kidney Disease Education Services | 20% coinsurance |
| Glaucoma Screening | 20% coinsurance |
| Diabetes Self-Management Training | No charge |
| Digital Rectal Exams | No charge |
| Welcome to Medicare EKG | No charge |
| Dental — Medicare-Covered Services | 20% coinsurance |
| Vision — Eye Exams | 20% coinsurance |
| Vision — Eyewear | 20% coinsurance |
| Hearing — Exams | 20% coinsurance |
| Hearing — Exams | See plan details |
| Hearing — Routine Exams | No charge |
| Hearing — Fitting & Evaluation for Hearing Aid | No charge |
| Hearing — Prescription Hearing Aids | See plan details |
| Home Health Services | No charge |
| Chiropractic Services | 20% coinsurance |
| Physician Specialist Services | 20% coinsurance |
| Podiatry Services | 20% coinsurance |
| Other Health Care Professional Services | 20% coinsurance |
| Psychiatric Services | See plan details |
| Skilled Nursing Facility (SNF) | $0/day for days 1–20, $221/day for days 21–100 |
| Cardiac & Pulmonary Rehabilitation | See plan details |
| Cardiac Rehabilitation — Additional Sessions | 20% coinsurance |
| Intensive Cardiac Rehabilitation — Additional Sessions | 20% coinsurance |
| Pulmonary Rehabilitation — Additional Sessions | 20% coinsurance |
| Supervised Exercise Therapy (SET) | 20% coinsurance |
| Emergency Services | $130 |
| Urgently Needed Services | $25 |
| Partial Hospitalization Program | 20% coinsurance |
| Physical Therapy & Speech-Language Pathology | 20% coinsurance |
| Opioid Treatment Program Services | 20% coinsurance |
| Radiological Services | See plan details |
| Diagnostic Radiology | 20% coinsurance |
| Therapeutic Radiology | 20% coinsurance |
| Ambulatory Surgical Center (ASC) | 0%-20% coinsurance |
| Substance Abuse — Group Sessions | 20% coinsurance |
| Ground Ambulance | 20% coinsurance |
| Air Ambulance | 20% coinsurance |
| Durable Medical Equipment (DME) | 20% coinsurance |
| Prosthetics & Orthotics | See plan details |
| Prosthetic Devices | 20% coinsurance |
| Medical Supplies | 0%-20% coinsurance |
| Diabetic Supplies & Services | See plan details |
| Diabetic Supplies | 20% coinsurance |
| Diabetic Therapeutic Shoes & Inserts | 20% coinsurance |
| Diabetic Monitors | 0%-20% coinsurance |
| Dialysis Services | 20% coinsurance |
| Medicare-Covered Preventive Services | See plan details |
| Remote Access Technologies | No charge |
| Insulin (Part B) | $35 |
| Hearing — Hearing Aids (All Types) | $549-$1,299 |
| Hearing — OTC Hearing Aids | $999 |
| Intensive Outpatient Program (IOP) | 20% coinsurance |
| Primary Care Physician Services | 20% coinsurance |
| Occupational Therapy Services | 20% coinsurance |
| Psychiatric Services — Individual Sessions | 20% coinsurance |
| Psychiatric Services — Group Sessions | 20% coinsurance |