| SERVICE | COST |
| Inpatient hospital coverage | In-Network:
$350 per stay
Out-of-Network:
$350 per stay
|
| Outpatient hospital coverage | In-Network:
$250 per visit
Out-of-Network:
$250 per visit
|
| Doctor visits | Primary:
In-Network:
$5 per visit
Out-of-Network:
$5-90 per visit
Specialist:
In-Network:
$30 per visit
Out-of-Network:
$30-250 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:
$5-35 per visit (always covered)
|
| Diagnostic procedures/lab services/imaging | Diagnostic tests and procedures:
In-Network:
$0-90
Out-of-Network:
$0-90
Lab services:
In-Network:
$0-40
Out-of-Network:
$0-90
Diagnostic radiology services (e.g., MRI):
In-Network:
$30-250
Out-of-Network:
$30-250
Outpatient x-rays:
In-Network:
$5-90
Out-of-Network:
$5-90
|
| Mental health services | In-Network:
$350 per stay
Out-of-Network:
$350 per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:
$30
Out-of-Network:
$30-250
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$30
Out-of-Network:
$30-250
Outpatient group therapy visit:
In-Network:
$30
Out-of-Network:
$30-250
Outpatient individual therapy visit:
In-Network:
$30
Out-of-Network:
$30-250
|
| Skilled Nursing Facility | In-Network:
$0 for days 1 through 20
$167.50 for days 21 through 100
Out-of-Network:
$0 for days 1 through 20
$167.50 for days 21 through 100
|
| Rehabilitation services | Occupational therapy visit:
In-Network:
$10-40
Out-of-Network:
$10-40
Physical therapy and speech and language therapy visit:
In-Network:
$10-40
Out-of-Network:
$10-40
|
| Ambulance | In-Network:
$265 or 20%
Out-of-Network:
$265 or 20%
|
| Transportation | Not covered
|
| Foot care (podiatry services) | Foot exams and treatment:
In-Network:
$30
Out-of-Network:
$30-250
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
Out-of-Network:
20% per item
Diabetes supplies:
In-Network:
$0 or 10-20% per item
Out-of-Network:
$10 or 10-20% per item
|
| Wellness programs (e.g., fitness, nursing hotline) | Covered
|
| Medicare Part B drugs | Chemotherapy:
In-Network:
20%
Out-of-Network:
20%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
20%
|
