| 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
|
| Outpatient hospital coverage | In-Network:
$225 per visit
Out-of-Network:
40% per visit
|
| 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
|
| Preventive care | In-Network:
$0 copay
Out-of-Network:
0-40%
|
| Emergency care/Urgent care | Emergency:
$80 per visit (always covered)
Urgent care:
$30-40 per visit (always covered)
|
| 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
|
| 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
|
| 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
|
| 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
|
| Ambulance | In-Network:
$250
Out-of-Network:
$250
|
| Transportation | Not covered
|
| 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
|
| 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
|
| Wellness programs (e.g., fitness, nursing hotline) | Covered
|
| Medicare Part B drugs | Chemotherapy:
In-Network:
20%
Out-of-Network:
40%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
40%
|
