Page 74 - Cover letter and evaluation for Michele Buros

Your Medicare Health Plan Details https://www.medicare.gov/find-a-plan/results/planresults/plan-details.as...

Rehabilitation services Occupational therapy visit:
In-Network: $15
Out-of-Network: 20%

Physical therapy and speech and language therapy visit:
In-Network: $15
Out-of-Network: 20%

Ambulance
In-Network: $195
Out-of-Network: $195

Transportation Not covered

Foot care (podiatry services) Foot exams and treatment:
In-Network: $25
Out-of-Network: 20%

Routine foot care: Not covered

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: 20%

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

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Benefits Services

Hearing
Hearing exam In-Network: $25
Out-of-Network: 20%

Fitting/evaluation In-Network: $25
Out-of-Network: 20%

There may be limits on how much the plan will provide.
Hearing aids In-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Preventive dental

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