(continued) Admissions for Inpatient Medical and Surgical Care and other and other and other 21 Physician Physician Physician covered professional covered professional covered professional provider services: Full provider services: The provider services: Nothing benefits less the Part B Part B and for as many days as are deductible and Part B Part B deductible coinsurance medically necessary for as many (full benefits when covered coinsurance days as are by Medex only) for as many medically days as are necessary medically necessary Chiropractor Services Full benefits less the Part B The Part B and Nothing 22 deductible and Part B Part B deductible coinsurance coinsurance within 100 days after discharge to treat a condition Continued Active Care hospital for which you were an in a for at least three days in a row inpatient hospital Full benefits less the Part B The Part B and Nothing 22 deductible and Part B Part B deductible coinsurance (includes: (includes: cardiac coinsurance cardiac rehabilitation; drugs rehabilitation; covered covered by by Part B; Medicare Medicare Part B; medical care medical care services; and services; and approved Medicare Medicare approved shortterm shortterm rehabilitation rehabilitation therapy) therapy) Diabetic Testing Materials, Enteral Formulas and Food Products When covered by When covered by When covered by 23 full benefits less the Part B nothing Medicare, Medicare, Medicare, the Part B and and Part B deductible deductible Part B coinsurance coinsurance When not covered by When not covered by When not covered by 23 nothing full benefits for: nothing for Medicare, Medicare, Medicare, diabetic testing materials; diabetic testing materials certain enteral formulas; and certain enteral and low protein food formulas: and all charges products for up to $2,500 Medex has provided per calendar year benefits for $2,500 per calendar year for low protein food products *Benefits for covered services are provided based on the allowed charge. You may have to pay any amount over the allowed charge. (See Parts 2 and 9.) Dialysis Services
Admissions for Inpatient Medical and Surgical Care (continued) Physician and other covered professional provider services: Full benefits less the Part B deductible and Part B coinsurance for as many days as are medically necessary Physician and other covered professional provider services: The Part B deductible and Part B coinsurance (full benefits when covered by Medex only) for as many days as are medically necessary Physician and other covered professional provider services: Nothing for as many days as are medically necessary 21 Chiropractor Services Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 22 Continued Active Care within 100 days after hospital discharge to treat a condition for which you were an inpatient in a hospital for at least three days in a row Full benefits less the Part B deductible and Part B coinsurance (includes: cardiac rehabilitation; drugs covered by Medicare Part B; medical care services; and Medicare approved shortterm rehabilitation therapy) The Part B deductible and Part B coinsurance (includes: cardiac rehabilitation; covered by Medicare Part B; medical care services; and Medicare approved shortterm rehabilitation therapy) Nothing 22 Diabetic Testing Materials, Enteral Formulas and Food Products When covered by Medicare, full benefits less the Part B deductible and Part B coinsurance When covered by Medicare, the Part B deductible and Part B coinsurance When covered by Medicare, nothing 23 When not covered by Medicare, nothing When not covered by Medicare, full benefits for: diabetic testing materials; certain enteral formulas; and low protein food products for up to $2,500 per calendar year When not covered by Medicare, nothing for diabetic testing materials and certain enteral formulas: and all charges Medex has provided benefits for $2,500 per calendar year for low protein food products 23 *Benefits for covered services are provided based on the allowed charge. You may have to pay any amount over the allowed charge. (See Parts 2 and 9.) Dialysis Services
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