PLAN L MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR **** Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* 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 $0 $[183] (Part B Approved Amounts**** deductible)**** ♦ Preventive Benefits for Generally 75% or more Remainder of Medicare All costs above Medicare Medicare covered services of Medicare approved approved amounts approved amounts amounts Remainder of Medicare Generally 80% Generally 15% Generally 5% ♦ Approved Amounts Part B Excess Charges $0 $0 All costs (and they do not (Above Medicare Approved count toward annual Amounts) limit of [$2620])* BLOOD First 3 pints $0 75% 25%♦ Next $[183] of Medicare Approved $0 $0 $[183] (Part B Amounts**** deductible) ♦ Remainder of Medicare Approved Generally 80% Generally 15% Generally 5%♦ Amounts CLINICAL LABORATORY SERVICES—TESTS FOR 100% $0 $0 DIAGNOSTIC SERVICES (continued) * This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[2620] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called and you will be responsible for paying this difference in “Excess Charges”) the amount charged by your provider and the amount paid by Medicare for the item or service. PLAN L PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY*
PLAN L MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR **** Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* 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**** Preventive Benefits for Medicare covered services Remainder of Medicare Approved Amounts $0 Generally 75% or more of Medicare approved amounts Generally 80% $0 Remainder of Medicare approved amounts Generally 15% $[183] (Part B deductible)**** ♦ All costs above Medicare approved amounts Generally 5% ♦ Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs (and they do not count toward annual limit of [$2620])* BLOOD First 3 pints Next $[183] of Medicare Approved Amounts**** Remainder of Medicare Approved Amounts $0 $0 Generally 80% 75% $0 Generally 15% 25%♦ $[183] (Part B deductible) ♦ Generally 5%♦ CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 (continued) * This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[2620] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. PLAN L PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY*
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