Prescription Drugs | |||
Initial Coverage Limit (ICL) | $4,430 | ||
Dental | |||
Comprehensive Dental Maximum Benefit | $2,500 | ||
Vision | |||
Eyewear Lenses and Frames | $320 maximum benefit
(up to 2 pairs / $160 per eyeglasses) | ||
Hearing Services | |||
Hearing Aids | $2,100 maximum benefit / 3 years ($1,050 per hearing aid per ear) | ||
Drugs/OTC | |||
OTC | $25 per quarter | ||
Part B Premium Give Back | |||
Part B Premium Reduction | $110 per month | ||
Acupuncture | |||
Routine | $0 for 6 visits | ||
Medical | |||
PCP Visit | $0 | ||
Inpatient Hospital (per admission) | $50 copay per day for 1-5 $0 copay per day for 6-90 $0 copay per day for 91+ | ||
Lab Services and X-Rays | $0 |
Prescription Drugs | |
Initial Coverage Limit (ICL) | |
$4,430 | |
Dental | |
Comprehensive Dental Maximum Benefit | |
$2,500 | |
Vision | |
Eyewear Lenses and Frames | |
$320 maximum benefit
(up to 2 pairs / $160 per eyeglasses) |
|
Hearing Services | |
Hearing Aids | |
$2,100 maximum benefit / 3 years ($1,050 per hearing aid per ear) | |
Drugs/OTC | |
OTC | |
$25 per quarter | |
Part B Premium Give Back | |
Part B Premium Reduction | |
$110 per month | |
Acupuncture | |
Routine | |
$0 for 6 visits | |
Medical | |
PCP Visit | |
$0 | |
Inpatient Hospital (per admission) | |
$50 copay per day for 1-5 $0 copay per day for 6-90 $0 copay per day for 91+ | |
Lab Services and X-Rays | |
$0 |

Membership Benefits
This plan provides great savings with a yearly allowance o $1,320 or $110 per month for your Part B.