| SERVICE | COST |
| Inpatient hospital coverage | In-Network:
$395 for days 1 through 4
$0 for days 5 through 90
$0 for days 91 and beyond
Out-of-Network:
Not Applicable
|
| Outpatient hospital coverage | In-Network:
$395 per visit
|
| Doctor visits | Primary:
In-Network:
$20 per visit
Specialist:
In-Network:
$45 per visit
|
| Preventive care | In-Network:
$0 copay
Out-of-Network:
$0 copay
|
| Emergency care/Urgent care | Emergency:
$80 per visit (always covered)
Urgent care:
$20-45 per visit (always covered)
|
| Diagnostic procedures/lab services/imaging | Diagnostic tests and procedures:
In-Network:
$0-105
Lab services:
In-Network:
$0-35
Out-of-Network:
$0 copay
Diagnostic radiology services (e.g., MRI):
In-Network:
$45-395
Outpatient x-rays:
In-Network:
$20-95
|
| Mental health services | In-Network:
$395 for days 1 through 3
$0 for days 4 through 90
Out-of-Network:
Not Applicable
Outpatient group therapy visit with a psychiatrist:
In-Network:
$40
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$40
Outpatient group therapy visit:
In-Network:
$40
Outpatient individual therapy visit:
In-Network:
$40
|
| Skilled Nursing Facility | In-Network:
$0 for days 1 through 20
$167.50 for days 21 through 100
Out-of-Network:
Not Applicable
|
| Rehabilitation services | Occupational therapy visit:
In-Network:
$20-40
Physical therapy and speech and language therapy visit:
In-Network:
$20-40
|
| Ambulance | In-Network:
$265 or 20%
|
| Transportation | Not covered
|
| Foot care (podiatry services) | Foot exams and treatment:
In-Network:
$45
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
Diabetes supplies:
In-Network:
$0 or 10-20% per item
Out-of-Network:
20% per item
|
| Wellness programs (e.g., fitness, nursing hotline) | Covered
|
| Medicare Part B drugs | Chemotherapy:
In-Network:
20%
Other Part B drugs:
In-Network:
20%
|
