Page 30 - Benefits-Guide-2020

MEDICAL PLANS | Summary of Benefits | Continued
Supplement-Type Standard Plan
10% coinsurance.
Member pays $0.
$5 copay per visit
to a Primary Care Physician (PCP)
or retail health clinic.
$40 copay per visit to a specialist.
10% coinsurance for allergy testing and allergy injections.
$10 copay per visit to a Primary Care Physician (PCP)
or retail health clinic.
$25 copay per visit to a specialist.
10% coinsurance for allergy testing and allergy injections.
10% coinsurance.
Member pays $0.
$75 copay for each emergency room visit.
$75 copay for each emergency room visit.
$0 copay until 100 days, member pays 100% of all charges beyond 100 days.
Prior hospital stay may be required.
$0 copay until 100 days, member pays 100% of all charges beyond 100 days.
Prior hospital stay may be required.
$0 copay for days 1-20 and $50 copay per day for days 21-100 per benefit period.
No prior hospital stay required.
Your provider must obtain approval from the plan before you get skilled nursing care. This is called getting prior authorization.
$0 copay for days 1-20 and $50 copay per day for days 21-100 per benefit period.
No prior hospital stay required.
Your provider must obtain approval from the plan before you get skilled nursing care. This is called getting prior authorization.
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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Supplement-Type Enhanced Plan
Medicare Advantage Standard Plan
Medicare Advantage Enhanced Plan
SKILLED NURSING FACILITY EMERGENCY CARE DOCTOR VISITS (PRIMARY & SPECIALISTS)