$5 copay per visit

$260 copay per day for days 1-5, $0 copay per day for days 6-90 (Unlimited days per admission).

$10 copay per day for days 1-20, $160 copay per day for days 21-51, $0 copay per day for days 52-100 (no prior hospital stay required).

$130 copay per visit (NOT waived if admitted within 48 hours)

$0 copay for Medicare-covered urgently-needed-care visits

$250 copay per trip (waived if admitted)

$0 copay for Medicare-covered Dental Services

This plan includes: Eye Exams, Eyewear.

$0 copay for Medicare-covered Hearing Services

$0 copay; Maximum plan benefit coverage of $15.00 every month (no rollover).

$0 copay for Fitness Benefit.