| Choice Rx HMO1 |
|
Monthly Premium2
$139
|
|
Primary Care Physician Office Visit Copayment
$0
|
|
MD Live4
$0
|
|
Specialist Office Visit Copayment
$35
|
|
Routine Annual Physical Exam Copayment
$0
|
|
Urgent Care Copayment
$50 worldwide coverage
|
|
Emergency Room Copayment3
$100 worldwide coverage
|
|
Ambulance
$185
|
|
Outpatient Surgery
$200-$250
|
|
Physical Therapy
$25
|
|
Inpatient Hospitalization
Days 1-6: $260 per day
|
|
Dental allowance for all dental services: Routine cleaning/restorative/dentures to use at any dentist in the U.S.
$1,500
|
|
Vision: Annual Routine Eye Exam
$35
|
|
TruHearing® Hearing Aid Benefit (per ear)
$299 / $499 / $799
|
|
Silver&Fit® Included
Yes
|
|
Lab Services
$0 or $5
|
|
X-rays
$5
|
|
Advanced Imaging Studies (CT, MRI, etc.)
$175
|
|
Out-of-Pocket (OOP) Max
$6,400
|
|
Plan Documents
Evidence of Coverage (EOC) & Summary of Benefits (SOB) Information
|
|
View a side-by-side comparison
Medicare Advantage Plan Options
|