Medicare Plans

Maximum

Out-of-Pocket

Inpatient Hospital Coverage¹

Days 1-6 $295/day copayment

Days 7 and beyond $0 copayment

Outpatient Surgery Services¹

 $295 copayment

Primary Care Provider

$0 copayment

Specialist

$30 copayment

Preventive Care

$0 copayment

Emergency Room

$90 copayment

Urgent Care

$45 copayment

Low Cost Labs

$0 copayment

Lab and Clinical Diagnostic Tests

$15 copayment

Outpatient X-rays

$25 copayment

Ultrasound, EKGs, EEGs, Stress Test

$35 copayment

Radiation Therapy

$60 copayment

Diagnostic Radiology Services (Such as MRIs, CT Scans)

$125 copayment

Medicare Covered Hearing Exams

$10 copayment

Medicare Covered Dental¹

$50 copayment

(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

Supplemental Dental

One exam and cleaning per year with Delta Dental Medicare Advantage Provider.

$30 copayment

Medicare Covered

Eye Exam

$50 copayment

Supplemental Vision

$10 copayment

Inpatient Mental Health Care

Days 1-5 $295 copayment/day

Days 6-190 $0 copayment including “lifetime reserve days” 

Outpatient Mental Health Care

Individual or group therapy

$40 copayment

Skilled Nursing Facility¹

Days 1-20 $0 copayment/day

Days 21-49 $172 copayment/day

Days 50-100 $0 copayment

Prior 3 day inpatient hospital stay not required

Physical Therapy

$30 copayment

Ambulance

$225 copayment

Transportation

Not covered

Medicare Part B Drugs and Chemotherapy

20%

Medicare Part D Drugs

Covered

Chiropractic Care

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):

$20 copayment

Diabetes Monitoring Supplies and Test Strips¹

One Touch™ and Accu-Chek™

(All other brands are not covered)

$0 copayment, applies up to a 90-day supply

Diabetes Self-Monitoring Training¹

$0 copayment

Theraputic Shoes/Inserts¹

$10 copayment

Prosthetic Devices¹

20% of the cost

Related Medical Supplies¹

20% of the cost

Home Health Care¹

$0 copayment