Page 69 - Cover letter and evaluation for Peter Smith

11/27/2017 Your Medicare Health Plan Details
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: $325
Out-of-Network: $325

Transportation Not covered

Foot care (podiatry services) Foot exams and treatment:
In-Network: $45
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: 0-20% per item
Out-of-Network: 0-20% per item

Wellness programs (e.g., fitness, Covered
nursing hotline)
Medicare Part B drugs Chemotherapy:
In-Network: 20%
Out-of-Network: 40%

Other Part B drugs:
In-Network: 20%
Out-of-Network: 40%

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Benefits Services
Hearing
Hearing exam In-Network: $45
Out-of-Network: 40%

Fitting/evaluation In-Network: $45
Out-of-Network: 40%

There may be limits on how much the plan will provide.
Hearing aids - inner ear Not covered

Hearing aids - outer ear Not covered
Hearing aids - over the ear Not covered

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=055&sgmntid=0#plan_benefits 3/5