SERVICE | COST |
Inpatient hospital coverage | $250 for days 1 through 7 $0 for days 8 through 90
|
Outpatient hospital coverage | $175 per visit
|
Doctor visits | Primary: $0 copay Specialist: $25 per visit
|
Preventive care | $0 copay
|
Emergency care/Urgent care | Emergency: $80 per visit (always covered) Urgent care: $25 per visit (always covered)
|
Diagnostic procedures/lab services/imaging | Diagnostic tests and procedures: $10 Lab services: $10 Diagnostic radiology services (e.g., MRI): $100 Outpatient x-rays: $10
|
Mental health services | $250 for days 1 through 6 $0 for days 7 through 90 Outpatient group therapy visit with a psychiatrist: $25 Outpatient individual therapy visit with a psychiatrist: $25 Outpatient group therapy visit: $25 Outpatient individual therapy visit: $25
|
Skilled Nursing Facility | $0 for days 1 through 20 $160 for days 21 through 100
|
Rehabilitation services | Occupational therapy visit: $25 Physical therapy and speech and language therapy visit: $25
|
Ambulance | $150
|
Transportation | Not covered
|
Foot care (podiatry services) | Foot exams and treatment: $25 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%
|