SERVICE | COST |
Inpatient hospital coverage | $0 copay per stay |
Outpatient hospital coverage | $0 copay |
Doctor visits | Primary:$0 copay Specialist:$0 copay |
Preventive care | $0 copay |
Emergency care/Urgent care | Emergency:$0 copay Urgent care:$0 copay |
Diagnostic procedures/lab services/imaging | Diagnostic tests and procedures:$0 copay Lab services:$0 copay Diagnostic radiology services (e.g., MRI):$0 copay Outpatient x-rays:$0 copay |
Mental health services | Inpatient hospital - psychiatric:$0 copay per stay Outpatient group therapy visit with a psychiatrist:$0 copay Outpatient individual therapy visit with a psychiatrist:$0 copay Outpatient group therapy visit:$0 copay Outpatient individual therapy visit:$0 copay |
Skilled Nursing Facility | $0 copay |
Rehabilitation services | Occupational therapy visit:$0 copay Physical therapy and speech and language therapy visit:$0 copay |
Ground ambulance | $0 copay |
Transportation | $0 copay. There may be limits on how much the plan will provide. |
Foot care (podiatry services) | Foot exams and treatment:$0 copay Routine foot care:Not covered |
Medical equipment/supplies | Durable medical equipment (e.g., wheelchairs, oxygen):$0 copay Prosthetics (e.g., braces, artificial limbs):$0 copay Diabetes supplies:$0 copay |
Wellness programs (e.g., fitness, nursing hotline) | Covered |
Medicare Part B drugs | Chemotherapy:$0 copay Other Part B drugs:$0 copay |