Monthly Premium
You must continue to pay your Medicare Part B premium. If you have a late enrollment penalty, it will still apply.
$110*
Max out of pocket
$4,500
Deductible
$0
Copays (PCP/Specialist)
$15/$40
Dental
$0 preventive - 2 cleanings; 2 exams & a set of bite-wing x-rays; 50% coinsurance for comprehensive services with $3,000 max benefit allowance; must use Delta Dental.
Over-the-counter (OTC) benefit
$90 allowance/quarter and can rollover; must use NationsOTC.
Vision
$0 routine exam. $150 yearly allowance for eyeglasses or contact lenses. 20% discount over $150 base allowance for frames, lenses, lens options. 40% discount applies on the purchase of any additional eyeglasses; must use EyeMed.
Hearing / Hearing Aids
$0 routine exam. Copays for hearing aids - 1 per ear/per year; must use NationsHearing.
Inpatient Hospital
$300/day for days 1-5; $0/day for days 6-90
Preventive Care
No copay for services considered preventive.
Outpatient Diagnostics Labs, Procedures, Tests
$0 - $200 depending on service.
Emergency Room / Urgent Care
$90/$55 no limit; worldwide coverage
Physical, Occupational and Speech Therapy
$15 copay
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Plan Documents