| 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.
