The following is effective as of January 1, 2025.
After you meet the Medicare and plan Deductibles, the services set forth below are covered, subject to the copayment shown. The service must have been covered by Medicare to be eligible for benefits under this section. Copays are limited to one copay per provider per date of service.
- Primary Care Physician Office Visits: $15 copayment per visit
- Specialist Office Visit: $15 copayment per visit
- Allergy testing/injections: $15 copayment per visit
- X-rays: $15 copayment per visit
- Laboratory tests: $15 copayment per test
- Complex diagnostic and radiology services: $15 copayment per visit
- Radiation therapy: $15 copayment per visit
- Urgent Care Services: $15 copayment per visit
- Emergency Care (Professional Component): $15 copayment per visit
- Mental Health Care (Outpatient): $15 copayment per visit
- Substance Use Disorder Services (Outpatient): $15 copayment per visit
- Physical, Occupational, and Speech Therapy: $15 copayment per visit
- Cardiac Rehabilitation: $15 copayment per visit
- Pulmonary Rehabilitation: $15 copayment per visit
- Chiropractic Care: $15 copayment per visit
- Podiatry Care: $15 copayment per visit
- Vision Care: $15 copayment per visit