Notes

The following services listed are excluded from the combined in-network and out-of-network deductible:In-Network only: Ambulance ServicesChemotherapy Drugs and AdministrationContinuous Glucose MonitorDiabetic Monitoring SuppliesDiagnostic ColonoscopyDiagnostic MammographyDurable Medical EquipmentLab ServicesOther Medicare Part B DrugsOutpatient Blood ServicesPrimary Care Physician's OfficeSpecialist's OfficeBoth In-Network and Out-of-Network:Emergency Room ServicesMedicare Covered Preventive ServicesMedicare Part B Insulin DrugsServices not covered by Original Medicare (i.e., Supplemental Benefits)Urgently Needed Services at Urgent Care Centers

Plan Overview

Plan identifiers

Carrier contact