| SERVICE | COST |
| Inpatient hospital coverage | In-Network:$360 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 91 and beyond
Out-of-Network:40% per stay |
| Outpatient hospital coverage | In-Network:20% per visit
Out-of-Network:40% per visit |
| Doctor visits | Primary:
In-Network:$20 per visit
Out-of-Network:40% per visit
Specialist:
In-Network:$50 per visit
Out-of-Network:40% per visit |
| Preventive care | In-Network:$0 copay
Out-of-Network:$0 or 40% |
| Emergency care/Urgent care | Emergency:$90 per visit (always covered)
Urgent care:$20-50 or 40% per visit (always covered) |
| Diagnostic procedures/lab services/imaging | Diagnostic tests and procedures:
In-Network:$0-50 or 20%
Out-of-Network:40%
Lab services:
In-Network:$0-30 or 25%
Out-of-Network:40%
Diagnostic radiology services (e.g., MRI):
In-Network:$50-360 or 20%
Out-of-Network:40%
Outpatient x-rays:
In-Network:$20-50 or 20%
Out-of-Network:40% |
| Mental health services | Inpatient hospital - psychiatric:
In-Network:$318 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-Network:40% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:$40
Out-of-Network:40%
Outpatient individual therapy visit with a psychiatrist:
In-Network:$40
Out-of-Network:40%
Outpatient group therapy visit:
In-Network:$40
Out-of-Network:40%
Outpatient individual therapy visit:
In-Network:$40
Out-of-Network:40% |
| Skilled Nursing Facility | In-Network:$0 per day for days 1 through 20
$167.50 per day for days 21 through 100
Out-of-Network:40% per stay |
| Rehabilitation services | Occupational therapy visit:
In-Network:$35-40
Out-of-Network:40%
Physical therapy and speech and language therapy visit:
In-Network:$35-40
Out-of-Network:40% |
| Ground ambulance | In-Network:$265
Out-of-Network:$265 |
| Transportation | Not covered |
| Foot care (podiatry services) | Foot exams and treatment:
In-Network:$50
Out-of-Network:40%
Routine foot care:Not covered |
| Medical equipment/supplies | Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network:20% per item
Out-of-Network:20% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:20% per item
Out-of-Network:20-40% per item
Diabetes supplies:
In-Network:$0 or 10-20% per item
Out-of-Network:20-40% per item |
| Wellness programs (e.g., fitness, nursing hotline) | Covered |
| Medicare Part B drugs | Chemotherapy:
In-Network:20%
Out-of-Network:20%
Other Part B drugs:
In-Network:20%
Out-of-Network:20% |
