In-Network $0

In-Network $325 per day, days 1-5; $0 per day, days 6-90

In-Network $20 per day, days 1-20; $218 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 Frequencies vary by covered dental service.

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 $500 benefit amount (allowance) per ear, every year for hearing aids (Maximum two hearing aids every year)

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.