Page 28 - Benefits-Guide-2020

MEDICALPLANS | SummaryOfBenefits
Supplement-Type Standard Plan
Supplement-Type Enhanced Plan
Medicare Advantage Standard Plan
Medicare Advantage Enhanced Plan
$300
Only applies to Part B services, and must be satisfied before any Medicare Part B benefits are paid. The Medicare Part B deductible is included in this $300 calendar year deductible.
Note: Plan pays entire Medicare Part A deductible; member pays $0 of Medicare Part A deductible.
$0
$750
Deductible applies to Part A and Part B covered services as noted within each category following, prior to the copay or coinsurance, if any, being applied.
$0
$1,500
Only applies to Part
B services. All Part
B coinsurance and deductible amounts accrue towards the medical plan maximum annual out-of-pocket amount, with the exception of the foreign travel emergency
and urgently needed care deductible or coinsurance amounts.
$0
Excludes foreign travel emergency and urgently needed care.
$2,500
All copays, coinsurance, and deductible amounts accrue towards the medical plan maximum annual out-of-pocket amount, with the exception of the foreign travel emergency
and urgently needed care deductible or coinsurance amounts.
$2,500
All copays, coinsurance, and deductible amounts accrue towards the medical plan maximum annual out-of-pocket amount, with the exception of the foreign travel emergency
and urgently needed care deductible or coinsurance amounts.
Unless otherwise noted: For the Medicare Advantage Standard Plan, members must meet their calendar-year deductible for all Part A and Part B covered services before their copayment or coinsurance will apply. For the Supplement-Type Standard Plan, members have no deductible to meet for Part A services, but for Part B services, members must meet their calendar-year deductible before their coinsurance will apply.
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MAXIMUM ANNUAL OUT OF POCKET CALENDAR YEAR DEDUCTIBLE