Summary of Benefits

$0 copay for each Medicare-covered specialist visit

No referral required

Unlimited amount each year for preventive dental services

$0 copay for the following preventive dental benefits:

• Up to one oral exam every six months
• Up to one cleaning every six months
• Up to one fluoride treatment every six months
• Up to four dental x-ray visits every year

The combined total comprehensive dental benefits cannot exceed $3,000 every year. The comprehensive dental benefits include the following services up to a $3,000 combined limit every year:

• minor restorations (fillings)
• simple extractions
• dentures, one every five years. Prior authorization is required.
• denture repair and reline
• surgical extractions
• oral surgery
• periodontics
• endodontics
• crowns, one every five years, per tooth. No more than four per calendar year, with no more than two crowns per arch.
• mini-implants (lower arch only) and implant-supported denture (lower arch only)

*Prior authorization is required for dentures, periodontics, endodontics, crowns, mini-implants, and implant-supported dentures. Fixed bridges and all other dental implants, except for mini-implants, are not covered.

Diagnostic hearing and balance evaluations performed by your PCP to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider.

• $0 for up to one routine hearing exam every year
• $0 for up to three fittings for a hearing aid every three years
• $0 for 80 batteries per aid for non-rechargeable models every three years
• $1,500 allowance for hearing aids every three years

You must receive your care from a network provider. We will only pay for covered hearing services if you go to an in-network hearing provider. In most cases, you will have to pay for care that you receive from an out-of-network provider.

Covered services include:

• Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts.
• For people who are at high risk of glaucoma, we will cover one glaucoma screening each year. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older.
• For people with diabetes, screening for diabetic retinopathy is covered once per year.
• One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.)

Our plan offers supplemental vision coverage including:

• $0 copay for up to one routine vision exam every year.
• In addition to the cataract surgery benefit, the plan will cover up to $350 every year towards eyeglasses or contact lenses.

You must receive your care from a network provider. We will only pay for covered vision services if you go to an in-network vision provider. In most cases, you will have to pay for care that you receive from an out-of-network provider.

100 trips every year to plan-approved locations (e.g. doctor's office, pharmacy, and hospital). May consist of a car, shuttle, or van service depending on appropriateness for the situation and the member's needs. Rides must be scheduled at least one business day in advance except in special circumstances. Transportation is authorized for plan-approved locations only (e.g. doctor's office, pharmacy and hospital).

*Prior authorization is required for trips that exceed 50 miles for a one-way ride. Other prior authorization and scheduling rules apply.

Up to $200 per month may be spent for over-the-counter (OTC) items included in the OTC catalog (PDF), online ordering portal and/or qualified items at participating retail settings via a restricted spend debit card. There is no limit on the total number of items or orders a member may purchase. Any unused balance will automatically expire at the end of each month or upon disenrollment from the plan.

Members who qualify based on socioeconomic (LIS) status may use $200 of the monthly allowance towards qualifying Food & Produce at participating retail locations and/or FarmBox mail-order, item limits may apply and/or qualifying rent and utility services. Any unused balance will automatically expire at the end of each month or upon disenrollment from the plan.

Refer to the Evidence of Coverage (EOC) (PDF).

$0 copay for each Medicare-covered individual therapy visit

$0 copay for each Medicare-covered group therapy visit

$0 copay for each Medicare-covered individual therapy visit with a psychiatrist

$0 copay for each Medicare-covered group therapy visit with a psychiatrist

Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.