SERVICE | COST |
Inpatient hospital coverage | In-Network: $225 for days 1 through 7 $0 for days 8 through 90 $0 for days 91 and beyond Out-of-Network: 40% per stay
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Outpatient hospital coverage | In-Network: $225 per visit Out-of-Network: 40% per visit
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Doctor visits | Primary: In-Network: $0 copay Out-of-Network: $30-45 per visit Specialist: In-Network: $30 per visit Out-of-Network: $45 per visit
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Preventive care | In-Network: $0 copay Out-of-Network: 0-40%
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Emergency care/Urgent care | Emergency: $80 per visit (always covered) Urgent care: $30-40 per visit (always covered)
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Diagnostic procedures/lab services/imaging | Diagnostic tests and procedures: In-Network: 20% Out-of-Network: 40% Lab services: In-Network: $5 Out-of-Network: $5 Diagnostic radiology services (e.g., MRI): In-Network: 20% Out-of-Network: 40% Outpatient x-rays: In-Network: $14 Out-of-Network: $21
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Mental health services | In-Network: $225 for days 1 through 7 $0 for days 8 through 90 Out-of-Network: 40% per stay Outpatient group therapy visit with a psychiatrist: In-Network: $30 Out-of-Network: $35-45 Outpatient individual therapy visit with a psychiatrist: In-Network: $40 Out-of-Network: $35-45 Outpatient group therapy visit: In-Network: $30 Out-of-Network: $35-45 Outpatient individual therapy visit: In-Network: $40 Out-of-Network: $35-45
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Skilled Nursing Facility | In-Network: $0 for days 1 through 20 $160 for days 21 through 45 $0 for days 46 through 100 Out-of-Network: 40% per stay
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Rehabilitation services | Occupational therapy visit: In-Network: $30 Out-of-Network: $45 Physical therapy and speech and language therapy visit: In-Network: $30 Out-of-Network: $45
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Ambulance | In-Network: $250 Out-of-Network: $250
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Transportation | Not covered
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Foot care (podiatry services) | Foot exams and treatment: In-Network: $30 Out-of-Network: $45 Routine foot care: In-Network: $30 Out-of-Network: $45
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Medical equipment/supplies | Durable medical equipment (e.g., wheelchairs, oxygen): In-Network: 20% per item Out-of-Network: 50% per item Prosthetics (e.g., braces, artificial limbs): In-Network: 20% per item Out-of-Network: 40% per item Diabetes supplies: In-Network: $0 per item Out-of-Network: 40% per item
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Wellness programs (e.g., fitness, nursing hotline) | Covered
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Medicare Part B drugs | Chemotherapy: In-Network: 20% Out-of-Network: 40% Other Part B drugs: In-Network: 20% Out-of-Network: 40%
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