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  CORE D (Includes Rx) With Rx VALUE D (Includes Rx) With Rx ELITE D (Includes Rx) With Rx VALUE ELITE
Monthly Premium

$0

$31 $71

$0

$30
Annual Out-of-Pocket Maximum (Does not include Part D Rx.) $5,900 $4,900 $3,450 $4,900 $3,450
Primary Care Visit Copay $0 $0 $0 $0 $0
Specialist Visit Copay $45 $35 $25 $35 $25
Urgent Care (worldwide) $50/visit $40/visit $30/visit $40/visit $30/visit
Emergency Copay (worldwide) $90/visit $90/visit $90/visit $90/visit $90/visit
Lab Services Copay $15 $10 $5 $10 $5
Inpatient Hospital Coverage Copay

Days 1-5: $370/day
Days 6+: $0

Days 1-7: $275/day
Days 8+: $0

$325/stay

Days 1-7: $275/day
Days 8+: $0

$325/stay

Outpatient Surgery 1 $250 per surgery $200 per surgery $150 per surgery $200 copay per surgery $150 per surgery
Preventive Services 2 X X X X X
Skilled nursing facility Copay3 Days 1-20: $0
Days 21-100: $170/day
Days 1-20: $0 copay
Days 21-100: $160/day
Days 1-20: $0 copay
Days 21-100: $150/day
Days 1-20: $0
Days 21-100: $160/day
Days 1-20: $0
Days 21-100: $150/day
Prescription Drug Coverage4 X X X N/A N/A
Dental Benefit5
Optional Comprehensive Dental6 $48.10/month $48.10/month $48.10/month $48.10/month $48.10/month
Vision Benefit Initial routine eye exam each year:
$0 copay
Plan pays $100 per year
for frames, lenses, and contacts
Initial routine eye exam each year:
$0 copay
Plan pays $100 per year
for frames, lenses, and contacts
Initial routine eye exam each year:
$0 copay
Plan pays $100 per year
for frames, lenses, and contacts
Initial routine eye exam each year:
$0 copay
Plan pays $100 per year
for frames, lenses, and contacts
Initial routine eye exam each year:
$0 copay
Plan pays $100 per year
for frames, lenses, and contacts
Hearing copay Annual hearing exam: $45
Hearing aids: $700-$1,050 per aid
Limit: 1 per ear, per year
Annual hearing exam: $35
Hearing aids: $700-$1,050 per aid
Limit: 1 per ear, per year
Annual hearing exam: $25
Hearing aids: $700-$1,050 per aid
Limit: 1 per ear, per year
Annual hearing exam: $35
Hearing aids: $700-$1,050 per aid
Limit: 1 per ear, per year
Annual hearing exam: $25
Hearing aids: $700-$1,050 per aid
Limit: 1 per ear, per year
Over-the-Counter Benefit Card7
Massage Therapy for Chronic Conditions Copay 6 (60-minute) visits per year: $20 12 (60-minute) visits per year: $20 12 (60-minute) visits per year: $0 12 (60-minute) visits per year: $20 12 (60-minute) visits per year: $0
Meal Delivery8 N/A
Travel Benefits9 X X X X X
Fitness Benefit10 X X X X X