Page 53 - Cover Letter and Evaluation for Amy Prack
P. 53
Doctor visits Primary: $5 per visit
Specialist: $45 per visit
Preventive care $0 copay
Emergency care/Urgent care Emergency: $90 per visit (always covered)
Urgent care: $5-45 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures: $0-110
services/imaging
Lab services: $0-35
Diagnostic radiology services (e.g., MRI): $45-250
Outpatient x-rays: $5-95
Mental health services Inpatient hospital - psychiatric: $395 per day for days 1 through 3
$0 per day for days 4 through 90
Outpatient group therapy visit with a psychiatrist: $40
Outpatient individual therapy visit with a psychiatrist: $40
Outpatient group therapy visit: $40
Outpatient individual therapy visit: $40
Skilled Nursing Facility $0 per day for days 1 through 20
$172 per day for days 21 through 100
Rehabilitation services Occupational therapy visit: $10-40
Physical therapy and speech and language therapy visit: $10-40
Ground ambulance $265
Transportation $0 copay
Foot care (podiatry services) Foot exams and treatment: $45
Routine foot care: Not covered
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen): 20% per item
Prosthetics (e.g., braces, artificial limbs): 20% per item
Diabetes supplies: $0 or 10-20% per item
Wellness programs (e.g., fitness, Covered
nursing hotline)
Medicare Part B drugs Chemotherapy: 20%
Other Part B drugs: 20%
