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2Preventive dental services are 2 cleanings, 2 oral exams and 2 bitewing x-rays per year. $100 deductible for restorative and major dental services. Coinsurance applies. For the Medicare Blue Choice® Select (HMO) Plan, there is a $15 copay per service. 3Applies to prescription drugs in Tier 1 through Tier 4.

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URL: https://www.excellusformedicare.com/Global/FileLib/Product_Brochures_2022/EXC-16580_Medicare-Product-Brochure_ROC_PRINT_-_A11Y_PHG_09-24-2021.pdf