Page 33 - Benefits-Guide-2020

MEDICAL PLANS | Summary of Benefits | Continued
Supplement-Type Standard Plan
Supplement-Type Enhanced Plan
10% coinsurance.
Member pays $0.
10% coinsurance.
10% coinsurance.
*Medical Supplies refers to Medicare Part B - covered durable medical equipment and supplies, including diabetes testing equipment and supplies.
10% coinsurance.
Member pays $0.
$40 copay for physical therapy, occupational therapy, and speech language therapy visits.
Your provider must obtain approval before receiving services. This is called getting prior authorization.
$25 copay for physical therapy, occupational therapy, and speech language therapy visits.
Your provider must obtain approval before receiving services. This is called getting prior authorization.
10% coinsurance.
Member pays $0.
10% coinsurance per one-way trip.
Your provider must obtain approval before non-emergency ground, air, or water transportation. This
is called getting prior authorization.
10% coinsurance per one-way trip.
Your provider must obtain approval before non-emergency ground, air, or water transportation. This
is called getting prior authorization.
Member pays $0.
Member pays $0.
$40 copay for the
one time only hospice consultation. Deductible does
not apply.
$25 copay for the
one time only hospice consultation.
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.
Medicare Advantage Standard Plan
Medicare Advantage Enhanced Plan
| 33
HOSPICE CARE AMBULANCE PHYSICAL THERAPY MEDICAL SUPPLIES*