Premium$0Key Extra BenefitsDental Level 3, Routine Eye Exam, Eyewear Credit, OTC Catalog,

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Premium$0Key Extra BenefitsDental Level 4, Routine Eye Exam, Eyewear Credit, OTC Debit

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Premium$0 ; Part B Reabte: $30MOOP $6,700PCP$0Specialist$45Referrals RequiredNoInpatient Hospital$395 (days 1-4)Ambulatory Surgery Center$0

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Premium$0 ; Part B Rebate: $30MOOP $4,500PCP$0Specialist$30Referrals RequiredNoInpatient Hospital$295 (days 1-6)Ambulatory Surgery Center$0

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Premium$49MOOP $6,700PCP$5Specialist$45Referrals RequiredNoInpatient Hospital$395 (days 1-4)Ambulatory Surgery Center$0 or $395Outpatient Hospital$0 or $395Lab

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