Page 71 - Cover Letter and Evaluation for Amy Prack
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Preventive care $0 copay
Emergency care/Urgent care Emergency: $90 per visit (always covered)
Urgent care: $30-40 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures: $20
services/imaging
Lab services: $5
Diagnostic radiology services (e.g., MRI): $100
Outpatient x-rays: $14
Mental health services Inpatient hospital - psychiatric: $325 per day for days 1 through 4
$0 per day for days 5 through 90
Outpatient group therapy visit with a psychiatrist: $30
Outpatient individual therapy visit with a psychiatrist: $40
Outpatient group therapy visit: $30
Outpatient individual therapy visit: $40
Skilled Nursing Facility $0 per day for days 1 through 20
$160 per day for days 21 through 49
$0 per day for days 50 through 100
Rehabilitation services Occupational therapy visit: $35
Physical therapy and speech and language therapy visit: $35
Ground ambulance $200
Transportation Not covered
Foot care (podiatry services) Foot exams and treatment: $35
Routine foot care: $35
There may be limits on how much the plan will provide.
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 per item
Wellness programs (e.g., fitness, Covered
nursing hotline)
Medicare Part B drugs Chemotherapy: 20%
Other Part B drugs: 20%
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Benefits Services
Hearing
