| Skilled Nursing Facility (SNF) | $20/day for days 1–20, $221/day for days 21–100 |
| Cardiac & Pulmonary Rehabilitation | See plan details |
| Cardiac Rehabilitation — Additional Sessions | No charge |
| Intensive Cardiac Rehabilitation — Additional Sessions | No charge |
| Pulmonary Rehabilitation — Additional Sessions | No charge |
| Supervised Exercise Therapy (SET) | No charge |
| Emergency Services | $150 |
| Urgently Needed Services | $10 |
| Worldwide Emergency & Urgent Coverage | See plan details |
| Worldwide Emergency Coverage | $120 after $500 deductible |
| Partial Hospitalization Program | $55 after $500 deductible |
| Primary Care Physician Services | No charge |
| Chiropractic Services | $5 after $500 deductible |
| Chiropractic Services | See plan details |
| Occupational Therapy Services | $5 after $500 deductible |
| Physician Specialist Services | $5-$10 after $500 deductible |
| Podiatry Services | $25 after $500 deductible |
| Podiatry Services | No charge |
| Other Health Care Professional Services | $0-$10 |
| Psychiatric Services | See plan details |
| Psychiatric Services — Individual Sessions | $10 after $500 deductible |
| Psychiatric Services — Group Sessions | $10 after $500 deductible |
| Physical Therapy & Speech-Language Pathology | $10 after $500 deductible |
| Additional Telehealth Services (Part B) | No charge |
| Opioid Treatment Program Services | $10 after $500 deductible |
| Diagnostic Tests & Lab Services | See plan details |
| Laboratory Services | No charge |
| Radiological Services | See plan details |
| Diagnostic Radiology | $15 after $500 deductible |
| Therapeutic Radiology | No charge after $500 deductible |
| X-Ray Services | No charge after $500 deductible |
| Outpatient Hospital Services | $350 after $500 deductible |
| Hospital Observation Services | $75 per stay after $500 deductible |
| Ambulatory Surgical Center (ASC) | $100 after $500 deductible |
| Outpatient Substance Abuse Services | See plan details |
| Substance Abuse — Individual Sessions | $10 after $500 deductible |
| Substance Abuse — Group Sessions | $10 after $500 deductible |
| Outpatient Blood Services | No charge after $500 deductible |
| Ambulance Services | See plan details |
| Ground Ambulance | $300 after $500 deductible |
| Air Ambulance | $300 after $500 deductible |
| Non-Emergency Transportation — Health Facility | No charge |
| Durable Medical Equipment (DME) | 20% coinsurance after $500 deductible |
| Prosthetic Devices | 20% coinsurance after $500 deductible |
| Medical Supplies | 20% coinsurance after $500 deductible |
| Diabetic Supplies & Services | See plan details |
| Diabetic Supplies | No charge |
| Diabetic Therapeutic Shoes & Inserts | 20% coinsurance |
| Diabetic Monitors | No charge |
| Dialysis Services | 20% coinsurance after $500 deductible |
| 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 |
| In-Home Safety Assessment | No charge |
| Caregiver 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 |
| Welcome to Medicare EKG | No charge |
| Insulin (Part B) | 0%-20% coinsurance (max $35) after $500 deductible |
| Dental — Medicare-Covered Services | No charge |
| Vision — Eye Exams | $25 after $500 deductible |
| Vision — Eyewear | No charge |
| Intensive Outpatient Program (IOP) | $55 after $500 deductible |
| Home Health Services | No charge after $500 deductible |
| Diagnostic Procedures & Tests | No charge |
| Prosthetics & Orthotics | See plan details |
| Hearing — Exams | $10 after $500 deductible |