SERVICE | COST |
Inpatient hospital coverage | $0 or $8 per stay |
Outpatient hospital coverage | $0 or $2 per visit |
Doctor visits | Primary:$0 copay Specialist:$0 or $0-2 per visit |
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 or $0-1.50 Lab services:$0 or $0-1.50 Diagnostic radiology services (e.g., MRI):$0 or $0-2 Outpatient x-rays:$0 or $0-1.50 |
Mental health services | Inpatient hospital - psychiatric:$0 or $8 per stay Outpatient group therapy visit with a psychiatrist:$0 or $2 Outpatient individual therapy visit with a psychiatrist:$0 or $2 Outpatient group therapy visit:$0 or $2 Outpatient individual therapy visit:$0 or $2 |
Skilled Nursing Facility | $0 copay |
Rehabilitation services | Occupational therapy visit:$0 or $2 Physical therapy and speech and language therapy visit:$0 or $2 |
Ground ambulance | $0 copay |
Transportation | Not covered |
Foot care (podiatry services) | Foot exams and treatment:$0 or $0-2 Routine foot care:$0 copay. There may be limits on how much the plan will provide. |
Medical equipment/supplies | Durable medical equipment (e.g., wheelchairs, oxygen):0% or 0-20% per item Prosthetics (e.g., braces, artificial limbs):0% or 0-20% per item 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 |