In-Network $0

In-Network $50 per day, days 1-3; $0 per day, days 4-90

In-Network $0 per day, days 1-20; $50 per day, days 21-100

$150 If you are admitted to the hospital within 24 hours your cost share may be waived

In-Network: $0 copay for Medicare-covered urgently-needed-care visits.

In-Network $275

In-Network Preventive dental services: $0 for oral exams $0 for cleanings $0 for x-rays Comprehensive dental services: 50% for restorative services 50% for endodontic services 50% for periodontic services 50% for removeable prosthodontics 50% for fixed prosthodontics 50% for oral and maxillofacial surgery 50% for adjunctive services $500 benefit amount (allowance) every year for covered comprehensive dental services. Frequencies and medical necessity requirements vary by covered dental service. Covered preventive dental services do not count towards your annual benefit amount. See EOC for additional details on exclusions and limitations.

In-Network Eye Exams: $0 for Medicare-covered eye exams $0 for non-Medicare covered routine eye exam Maximum one non-Medicare covered routine eye exam every calendar year with an EyeMed network provider Eyewear: $0 for Medicare-covered prescription eyewear $100 annual benefit amount (allowance) for non-Medicare covered prescription eyewear through an EyeMed network provider. $0 for Contacts $0 for Eyeglasses $0 for Eyeglass Frames $0 for Eyeglass Lenses $0 for Upgrades

In-Network Hearing Exams: $0 for Medicare-covered hearing exams $0 for non-Medicare covered hearing exams (Maximum one non-Medicare covered hearing exam every year) $0 for fitting/evaluation for hearing aids (Maximum one hearing aid fitting/evaluation every year) Hearing Aids: $0 for hearing aids $1,250 benefit amount (allowance) per ear, every year for hearing aids (Maximum two hearing aids every year)

CVS Over-the-Counter (OTC) Wallet with a $15 quarterly benefit amount (allowance) on the Extra Benefits Card to help pay for approved OTC health and wellness products like first aid supplies, cold and allergy medicine, pain relievers, and more. Approved products can be purchased in-store at participating CVS retail locations (excluding locations inside other stores), using the app, online or by phone through CVS Flex Benefits. Qualifying members may be eligible for additional wallets. See EOC for more information.

In-Network: $275 copay

Fitness benefit that includes a basic membership to any SilverSneakers participating fitness facility. If you do not reside near a participating facility, or prefer to exercise at home, online classes and one at-home fitness kit per year are available through SilverSneakers at no additional cost to you.