| | VIP Plan
(HMO) | Gold Card (HMO) | Platinum Card (HMO) |
| Plan overview |
| Monthly plan premium | $0 | $0 | $58 |
| Deductible | $0 |
| Annual out-of-pocket maximum | $2,900 yearly limit for services you receive from in-network providers |
| Doctor visits |
| Primary care physician visit | $0 | $5 | $5 |
| Specialist visit | $0 | $20 | $20 |
| Preventive care | $0 |
| Lab services / X-rays | $0 / $10 | $0 / $10 | $0 / $0 |
| Diagnostic radiology (e.g., MRIs) | $75 | $75 | 15% of the cost |
| Hospital visits and emergencies |
| Inpatient hospital coverage | $225/day for days 1–7
$0/day for days 8 + | $150/day for days 1–8. $0/day for days 9 + |
| Outpatient hospital coverage | $0–100 | $20–225 | $20–$175 |
| Emergency care | $90 |
| Urgently needed services | $30 ($90 for worldwide urgent care and emergency coverage) |
| Supplemental benefits |
| Dental | $0 | $13 monthly premium | $0 |
| Routine eye exam (every 12 months) | $0 | $0 | $0 |
| Hearing aids | $3,000 allowance every 36 months | $3,000 allowance every 36 months | $3,500 allowance every 36 months |
| Silver&Fit® Fitness Benefit | $0 | $0 | $0 |
| Chiropractic care | $10, limit 30 visits per year (combined) | $10, limit 30 visits per year (combined) | $10, limit 30 visits per year (combined) |
| Acupuncture |
| Over-the-counter (OTC) items | Up to $100 per quarter | Up to $100 per quarter | Up to $125 per quarter |
| Medicare Part D drugs: initial coverage |
| Retail: 1-month supply | |
| Tier 1 (Preferred Generic) | $2 |
| Tier 2 (Generic) | $8 |
| Tier 3 (Preferred Brand) | $40 |
| Tier 4 (Non-preferred Brand) | $95 |
| Tier 5 (Specialty) | 33% of the cost |
| Tier 6 (Select Care)
| $0 |
| Mail order: 3-month supply | |
| Tier 1 (Preferred Generic) | $0 |
| Tier 2 (Generic) | $0 |
| Tier 3 (Preferred Brand) | $80 |
| Tier 4 (Non-preferred Brand) | $190 |
| Tier 5 (Specialty) | Not offered |
| Tier 6 (Select Care)
| $0 |