| Dental — Medicare-Covered Services | $0-$10 |
| Dental — Preventive | See plan details |
| Dental — Oral Exams | See plan details |
| Dental — X-Rays | See plan details |
| Dental — Prophylaxis (Cleaning) | See plan details |
| Dental — Fluoride Treatment | See plan details |
| Dental — Comprehensive | See plan details |
| Dental — Periodontics (Gum Care) | No charge |
| Dental — Adjunctive General Services | No charge |
| Vision — Eye Exams | $0-$10 |
| Vision — Eye Exams | See plan details |
| Vision — Routine Eye Exams | No charge |
| Vision — Eyewear | No charge |
| Hearing — Exams | $10 |
| Emergency Services | $150 |
| Urgently Needed Services | No charge |
| Worldwide Emergency & Urgent Coverage | See plan details |
| Worldwide Emergency Coverage | $150 |
| Worldwide Emergency Transportation | $250 |
| Partial Hospitalization Program | No charge |
| Intensive Outpatient Program (IOP) | No charge |
| Home Health Services | No charge |
| Primary Care Physician Services | No charge |
| Chiropractic Services | No charge |
| Occupational Therapy Services | $5-$10 |
| Physician Specialist Services | $10 |
| Podiatry Services | $10 |
| Other Health Care Professional Services | $0-$10 |
| Psychiatric Services | See plan details |
| Psychiatric Services — Individual Sessions | No charge |
| Psychiatric Services — Group Sessions | No charge |
| Physical Therapy & Speech-Language Pathology | $0-$10 |
| Additional Telehealth Services (Part B) | No charge |
| Opioid Treatment Program Services | No charge |
| Diagnostic Tests & Lab Services | See plan details |
| Diagnostic Procedures & Tests | No charge |
| Laboratory Services | No charge |
| Radiological Services | See plan details |
| Diagnostic Radiology | $0-$250 |
| Therapeutic Radiology | No charge |
| X-Ray Services | No charge |
| Outpatient Hospital Services | $0-$215 |
| Hospital Observation Services | $0-$150 |
| Ambulatory Surgical Center (ASC) | $215 |
| Outpatient Substance Abuse Services | See plan details |
| Substance Abuse — Individual Sessions | No charge |
| Substance Abuse — Group Sessions | No charge |
| Outpatient Blood Services | No charge |
| Ambulance Services | See plan details |
| Ground Ambulance | $250 |
| Air Ambulance | $250 |
| 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 |
| Diabetic Therapeutic Shoes & Inserts | No charge |
| Dialysis Services | No charge |
| Acupuncture | No charge |
| Insulin (Part B) | $7-$35 |
| Skilled Nursing Facility (SNF) | See plan details |
| Cardiac & Pulmonary Rehabilitation | See plan details |
| Cardiac Rehabilitation — Additional Sessions | $0-$10 |
| Intensive Cardiac Rehabilitation — Additional Sessions | $0-$10 |
| Pulmonary Rehabilitation — Additional Sessions | No charge |
| Supervised Exercise Therapy (SET) | No charge |
| Welcome to Medicare EKG | No charge |
| Over-the-Counter (OTC) Items | No charge |
| Other Supplemental Benefit | $100 |
| Other Supplemental Benefit | No charge |
| Medicare-Covered Preventive Services | See plan details |
| Annual Physical Exam | No charge |
| Health Education | No charge |
| Nutritional & Dietary 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 |