Page 32 - 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 for each x-ray visit and/or simple diagnostic test, complex diagnostic test and/or radiology visit.
Member pays $0 for clinical lab services, blood tests, urinalysis.
Member pays $0.
$40 copay for each X-ray visit and/or simple diagnostic test.
$0 copay for testing
to confirm chronic obstructive pulmonary disease. Deductible does not apply.
10% coinsurance for complex diagnostic test and/or radiology visit.
$0 copay for each clinical/diagnostic lab test.
Your provider must obtain approval from the plan for certain diagnostic studies including but not limited to PET, CT, and MRI scans. This is called getting prior authorization.
10% coinsurance for each X-ray visit and/or simple diagnostic test.
$0 copay for testing
to confirm chronic obstructive pulmonary disease.
10% coinsurance for complex diagnostic test and/or radiology visit.
$0 copay for each clinical/diagnostic lab test.
Your provider must obtain approval from the plan for certain diagnostic studies including but not limited to PET, CT, and MRI scans. This is called getting prior authorization.
10% coinsurance.
Non-emergency transportation must be medically necessary and supported by written order from doctor.
Member pays $0.
Non-emergency transportation is covered at 10% coinsurance with prior authorization from the plan.
Non-emergency transportation is covered at 10% coinsurance with prior authorization from the plan.
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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TRANSPORTATION (MEDICALLY NECESSARY) DIAGNOSTIC SERVICES/LABS/IMAGING