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
Specialist office visit $5 copay
Diagnostic lab/X-ray $0
Routine physical exam $0
Outpatient mental health $5
Ambulatory surgery $0
Ambulance $50 copay
Inpatient care $0
Anesthesia $0
Emergency room $50 copay (waived if admitted)
Routine hearing exam $5 copay
Routine vision exam $15 copay
Preventive dental care $5 copay for exam, $10 copay for cleaning, discounts for additional services
Prescription drugs Copays apply. See the Prescription Drug Benefits section.
Skilled nursing facility, non custodial $0 (up to 100 days per benefit period)
Home health care, non custodial $0
Private duty nursing $0
Durable medical equipment $0 (must be medically necessary)