Page 173 - Cover Letter and Evaluation for Sue Marx

2/7/2019 Your Medicare Health Plan Details
Rehabilitation services Occupational therapy visit:
In-Network: $25
Out-of-Network: 20%

Physical therapy and speech and language therapy visit:
In-Network: $25
Out-of-Network: 20%

Ground ambulance
In-Network: $225
Out-of-Network: $225

Transportation
In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Foot care (podiatry services) Foot exams and treatment:
In-Network: $25
Out-of-Network: 20%

Routine foot care:
In-Network: $25
Out-of-Network: 20%

There may be limits on how much the plan will provide.
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: 0-20% 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: 30%

Other Part B drugs:
In-Network: 20%
Out-of-Network: 30%

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Benefits Services

Hearing exam In-Network: $35
Out-of-Network: $0 copay

Fitting/evaluation In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5522&plnid=001&sgmntid=0#plan_benefits 3/6