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 primary care provider to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider.

• $0 for 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.

$0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk.

• One pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery.

$0 copay for the following supplemental vision benefits:

• Up to one supplemental routine eye exam every year.
• Up to one pair of eyeglasses (lenses and frames) every year.
• Up to one pair of contact lenses every year.

We pay up to $350 every year for contact lenses and eyeglasses (frames and lenses).

80 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. 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 $350 per quarter 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 $350 of the quarterly 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 quarter or upon disenrollment from the plan.

$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.