SERVICE | COST |
Inpatient hospital coverage | $265 for days 1 through 9 $0 for days 10 through 90
|
Outpatient hospital coverage | $250 or 20% per visit
|
Doctor visits | Primary: $5 per visit Specialist: $40 per visit
|
Preventive care | $0 copay
|
Emergency care/Urgent care | Emergency: $100 per visit (always covered) Urgent care: $35 per visit (always covered)
|
Diagnostic procedures/lab services/imaging | Diagnostic tests and procedures: 20% Lab services: $0 copay Diagnostic radiology services (e.g., MRI): 20% Outpatient x-rays: $20
|
Mental health services | $250 for days 1 through 7 $0 for days 8 through 90 Outpatient group therapy visit with a psychiatrist: $25 Outpatient individual therapy visit with a psychiatrist: $35 Outpatient group therapy visit: $25 Outpatient individual therapy visit: $35
|
Skilled Nursing Facility | $20 for days 1 through 20 $125 for days 21 through 100
|
Rehabilitation services | Occupational therapy visit: $30 Physical therapy and speech and language therapy visit: $30
|
Ambulance | $220
|
Transportation | $0 copay
|
Foot care (podiatry services) | Foot exams and treatment: $40 Routine foot care: Not covered
|
Medical equipment/supplies | Durable medical equipment (e.g., wheelchairs, oxygen): 20% per item Prosthetics (e.g., braces, artificial limbs): 20% per item Diabetes supplies: $0 copay
|
Wellness programs (e.g., fitness, nursing hotline) | Covered
|
Medicare Part B drugs | Chemotherapy: 20% Other Part B drugs: 20%
|