Summary of Benefits

$0 copay for each Medicare-covered specialist visit.

No referral required.

Unlimited plan coverage limit for preventive dental benefits every year.

$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-rays every year.

The combined total comprehensive dental benefits cannot exceed $3,600 every year. The comprehensive dental benefits include the following services up to a $3,600 combined limit every year:

• minor restorations (fillings)
• simple extractions
• dentures
• denture repair and reline
• surgical extractions
• oral surgery
• periodontics
• endodontics
• crowns
• mini-implants (lower arch only) and implant supported denture (lower arch only).

*Prior authorization is required for comprehensive dental services. Service limitations may apply.

Diagnostic hearing and balance evaluations are:

• $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.
• $2,500 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 everything original Medicare covers PLUS:

• $0 copay for up to one routine vision exam every year.
• The plan will cover up to $400 every year toward eyeglasses or contact lenses.

50 trips to plan-approved locations every year (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.

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

Benefit includes $250 per month 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.

Coverage includes Naloxone.

Members who qualify based on socioeconomic (LIS) status may use $250 of the monthly allowance toward qualifying food and produce at participating retail locations and/or FarmBox mail order (item limits may apply) and/or qualifying rent and utility services, internet services, pest control, and pet supplies. Any unused balance will automatically expire at the end of each month or upon disenrollment from the plan.

Personal emergency response system (PERS) is a medical alert monitoring system that provides 24/7 access to help at the push of a button. We offer multiple styles, including a mobile-enabled wearable device. One device per year.

$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.