Page 31 - Benefits-Guide-2020

MEDICAL PLANS | Summary of Benefits | Continued
Supplement-Type Standard Plan
Supplement-Type Enhanced Plan
Medicare Advantage Standard Plan
Medicare Advantage Enhanced Plan
10% coinsurance.
Member pays $0.
$40 copay for each visit.
$30 copay for each visit.
$0 for most exams and screenings, Medicare lists screenings that require deductible and coinsurance: https:// www.medicare.gov/ coverage/preventive- screening-services.
Coverage for expenses incurred for physical exams, preventive screening tests and services and any other tests or preventive measures determined to be appropriate by the attending physician, not otherwise covered by Medicare: Maximum plan benefit of $120 per calendar year; member pays all expenses over $120 calendar year maximum.
Diabetes Self- Management Training: $0 copay; 10% coinsurance.
$0 for most exams and screenings, Medicare lists screenings that require deductible and coinsurance: https:// www.medicare.gov/ coverage/preventive- screening-services.
Coverage for expenses incurred for physical exams, preventive screening tests and services and any other tests or preventive measures determined to be appropriate by the attending physician, not otherwise covered by Medicare: Maximum plan benefit of $120 per calendar year; member pays all expenses over $120 calendar year maximum.
Diabetes Self- Management Training: Member pays $0.
$0 copay.
For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost
to you. However, if you are treated or monitored for an existing
medical condition or
an additional non- preventive service, during the visit when you receive the preventive service,
a copay or coinsurance may apply for that
care received.
$0 copay.
For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost
to you. However, if you are treated or monitored for an existing
medical condition or
an additional non- preventive service, during the visit when you receive the preventive service,
a copay or coinsurance may apply for that
care received.
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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PREVENTIVE CARE URGENT CARE