Page 75 - Cover Letter & Evaluation for Michael Novotny
P. 75
6/9/2018 Your Medicare Health Plan Details
Doctor visits Primary: $0 copay
Specialist: $0 copay
Preventive care $0 copay
Emergency care/Urgent care Emergency: $75 per visit (always covered)
Urgent care: $0-10 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures: $0 copay
services/imaging
Lab services: $0 copay
Diagnostic radiology services (e.g., MRI): $0 copay
Outpatient x-rays: $0 copay
Mental health services $250 per stay
$120 for days 1 through 10
$0 for days 11 through 90
$0 for days 91 through 130
Outpatient group therapy visit with a psychiatrist: $40
Outpatient individual therapy visit with a psychiatrist: $40
Outpatient group therapy visit: $0 copay
Outpatient individual therapy visit: $0 copay
Skilled Nursing Facility $0 for days 1 through 20
$30 for days 21 through 100
Rehabilitation services Occupational therapy visit: $0 copay
Physical therapy and speech and language therapy visit: $0 copay
Ambulance $125
Transportation $0 copay
Foot care (podiatry services) Foot exams and treatment: $5
Routine foot care: $5
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen): 0-20% per item
Prosthetics (e.g., braces, artificial limbs): 20% per item
Diabetes supplies: $0 copay
Wellness programs (e.g., fitness, Covered
nursing hotline)
Medicare Part B drugs Chemotherapy: 20%
Other Part B drugs: 20%
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H3815&plnid=001&sgmntid=0#plan_benefits 2/5
