| SERVICE | COST |
| Inpatient hospital coverage | In-Network:
$300 for days 1 through 6
$0 for days 7 through 90
$0 for days 91 and beyond
Out-of-Network:
40% for days 1 and beyond
|
| Outpatient hospital coverage | In-Network:
$275 per visit
Out-of-Network:
40% per visit
|
| Doctor visits | Primary:
In-Network:
$20 per visit
Out-of-Network:
40% per visit
Specialist:
In-Network:
$50 per visit
Out-of-Network:
40% 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:
$65 per visit (always covered)
|
| Diagnostic procedures/lab services/imaging | Diagnostic tests and procedures:
In-Network:
20%
Out-of-Network:
40%
Lab services:
In-Network:
20%
Out-of-Network:
40%
Diagnostic radiology services (e.g., MRI):
In-Network:
20%
Out-of-Network:
40%
Outpatient x-rays:
In-Network:
20%
Out-of-Network:
40%
|
| Mental health services | In-Network:
$270 for days 1 through 6
$0 for days 7 through 90
Out-of-Network:
40% for days 1 through 190
Outpatient group therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
40%
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
40%
Outpatient group therapy visit:
In-Network:
$40
Out-of-Network:
40%
Outpatient individual therapy visit:
In-Network:
$40
Out-of-Network:
40%
|
| Skilled Nursing Facility | In-Network:
$0 for days 1 through 20
$167.50 for days 21 through 60
$0 for days 61 through 100
Out-of-Network:
40% for days 1 through 100
|
| Rehabilitation services | Occupational therapy visit:
In-Network:
$40
Out-of-Network:
40%
Physical therapy and speech and language therapy visit:
In-Network:
$40
Out-of-Network:
40%
|
| Ambulance | In-Network:
$250
Out-of-Network:
$250
|
| Transportation | Not covered
|
| Foot care (podiatry services) | Foot exams and treatment:
In-Network:
$50
Out-of-Network:
40%
Routine foot care:
Not covered
|
| Medical equipment/supplies | Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network:
20% per item
Out-of-Network:
40% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
40% per item
Diabetes supplies:
In-Network:
$0 copay
Out-of-Network:
40% per item
|
| Wellness programs (e.g., fitness, nursing hotline) | Not covered
|
| Medicare Part B drugs | Chemotherapy:
In-Network:
20%
Out-of-Network:
40%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
40%
|
