Summary of Benefits and Coverage:
What the Plan Covers and Costs

Benefits Summary: VIP Premier (HMO) Medicare
Medical Care Your In-Network Cost
PCP office visit $0 copay
Specialist office visit $25 copay
Diagnostic lab/X-ray $0 copay
Routine physical exam $0 copay
Outpatient mental health $5 copay
Ambulatory surgery $0 copay
Ambulance $50 copay
Inpatient care $100 per admission
Anesthesia $0 copay
Emergency room $75 copay (waived if admitted)
Routine hearing exam $5 copay
Routine vision exam $15 copay
Prescription drugs Copays apply. See the Prescription Drug Benefits section.
Skilled nursing facility, non custodial $0 copay (up to 100 days per benefit period)
Home health care, non custodial $0 copay
Private duty nursing $0 copay
Durable medical equipment 20% Coinsurance