Page 36 - 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 copay per visit to a Primary Care Physician (PCP) or retail health clinic.
$25 copay per visit to a specialist.
*Hearing services refer to Medicare-covered basic diagnostic hearing and balance exams; to determine if you need medical treatment, and these services are furnished by a physician, audiologist, or other qualified provider.
Deductible applies. 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 copay per visit to a Primary Care Physician (PCP) or retail health clinic.
$25 copay per visit to a specialist.
*Dental services refer to non-routine Medicare-covered services and are limited to: surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician.
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
DENTAL SERVICES* HEARING SERVICES*