MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as services, inpatient Physician’s and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[183] of Medicare $0 $[183] (Part B $0 Approved Amounts* deductible) Remainder of Medicare Generally 80% Generally 20% $0 Approved Amounts Part B Excess Charges (Above Medicare $0 $0 All costs Approved Amounts) BLOOD First 3 pints $0 All costs $0 Next $[183] of Medicare Approved $0 $[183] (Part B $0 Amounts* deductible) Remainder of Medicare Approved 80% 20% $0 Amounts CLINICAL LABORATORY SERVICES—TESTS FOR 100% $0 $0 DIAGNOSTIC SERVICES PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES necessary skilled 100% $0 $0 —Medically care services and medical supplies medical equipment —Durable First $[183] of Medicare $0 $[183] (Part B $0 Approved Amounts* deductible) Remainder of Medicare 80% 20% $0 Approved Amounts (continued) PLAN C OTHER BENEFITS—NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL—NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of Charges $0 80% to a lifetime 20% and amounts over maximum benefit of the $50,000 lifetime $50,000 maximum PLAN D MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD
MEDICAL EXPENSES—IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $[183] (Part B deductible) Generally 20% $0 $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $[183] (Part B deductible) 20% $0 $0 $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES —Medically necessary skilled care services and medical supplies —Durable medical equipment First $[183] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 100% $0 80% $0 $[183] (Part B deductible) 20% $0 $0 $0 (continued) PLAN C OTHER BENEFITS—NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL—NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of Charges $0 $0 $0 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum PLAN D MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD