expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the separate foreign travel emergency plan’s deductible. SERVICES MEDICARE PAYS [AFTER YOU PAY [IN ADDITION TO $[2240] $[2240] DEDUCTIBLE,**] DEDUCTIBLE,**] PLAN PAYS YOU PAY MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as services, physician’s inpatient 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 approved Generally 80% Generally 20% $0 amounts Part B Excess Charges (Above Medicare $0 100% $0 approved amounts) BLOOD First 3 pints $0 All costs $0 Next $[183] of Medicare $0 $[183] (Part B $0 approved amounts* deductible) Remainder of Medicare 80% 20% $0 approved amounts CLINICAL LABORATORY SERVICES-- TESTS 100% $0 $0 FOR DIAGNOSTIC SERVICES (continued) PLAN F or HIGH DEDUCTIBLE PLAN F PARTS A & B SERVICES MEDICARE PAYS [AFTER YOU PAY [IN ADDITION TO $[2240] $[2240] DEDUCTIBLE,**] DEDUCTIBLE,**] PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES ---Medically necessary skilled 100% $0 $0 care services and medical supplies ---Durable medical equipment First $[183] of Medicare $0 $[183] (Part B $0 approved amounts* deductible) Remainder of Medicare 80% 20% $0 approved amounts OTHER BENEFITS - NOT COVERED BY MEDICARE
expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible. SERVICES MEDICARE PAYS [AFTER YOU PAY $[2240] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2240] DEDUCTIBLE,**] 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* Remainder of Medicare approved amounts $0 Generally 80% $[183] (Part B deductible Generally 20% $0 $0 Part B Excess Charges (Above Medicare approved amounts) $0 100% $0 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 (continued) PLAN F or HIGH DEDUCTIBLE PLAN F PARTS A & B SERVICES MEDICARE PAYS [AFTER YOU PAY $[2240] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2240] DEDUCTIBLE,**] YOU PAY 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 OTHER BENEFITS - NOT COVERED BY MEDICARE
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