Page 79 - Cover Letter and Evaluation for Mike Peaseley
P. 79
11/17/2017 Your Medicare Health Plan Details
Doctor visits Primary: $10 per visit
Specialist: $45 per visit
Preventive care $0 copay
Emergency care/Urgent care Emergency: $75 per visit (always covered)
Urgent care: $10-45 per visit (always covered)
Diagnostic procedures/lab Diagnostic tests and procedures: $15
services/imaging
Lab services: $10
Diagnostic radiology services (e.g., MRI): 20%
Outpatient x-rays: $15
Mental health services $1,562 per stay
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 for days 1 through 20
$160 for days 21 through 100
Rehabilitation services Occupational therapy visit: $40
Physical therapy and speech and language therapy visit: $40
Ambulance $275
Transportation Not covered
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: 0-20% 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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https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H3931&plnid=126&sgmntid=0#plan_benefits 2/4
