•Annual Wellness Visit 
•Lung cancer screening 
•Routine physical exam 
•Medicare diabetes prevention program 
Any additional preventive services approved by Medicare during the 
contract year will be covered.  
EMERGENCY CARE 
Emergency room $90 copay 
If you are admitted to the hospital within 24 hours, you do not have to 
pay your share of the cost for the emergency care. 
Urgently needed services $20 copay at an urgent care center 
Urgently needed services are provided to treat anon-emergency,