treatment: Full treatment: The treatment: 26 Outpatient Outpatient Outpatient benefits less the Part B Part B and Nothing for and deductible Medicare and Part B Part B for as Medex for deductible coinsurance covered services (Nothing for many visits as are as many visits as are coinsurance medically services not covered by for and and necessary Medicare medically necessary; and nothing for up to 24 visits Medicare) covered services; full benefits when covered per calendar year for by Medex only for up to 24 services covered by Medex visits per calendar year only; then all charges Physical Therapist Services Full benefits less the Part B The Part B and Nothing for 26 deductible Medicare and Part B Part B for approved physical therapy deductible coinsurance for approved physical coinsurance Medicare Medicare approved physical therapy therapy Podiatry Care Full benefits less the Part B The Part B and Nothing 26 deductible and Part B Part B deductible coinsurance coinsurance Radiation and X-Ray Therapy Full benefits less the Part B The Part B and Nothing 27 deductible and Part B Part B deductible coinsurance coinsurance Routine Tests For routine For routine For routine 27 mammograms: Full mammograms: The Part B mammograms: Nothing benefits less the Part B (the Part B for one baseline coinsurance (the Part B does not for mammogram between coinsurance deductible does not apply) one baseline mammogram age 35 through 39; and one deductible for one baseline between age 35 through 39 routine mammogram per mammogram between and one routine year for a age 40 or member age 35 through 39 and one mammogram per year for a older routine mammogram per age 40 or older member year for a age 40 or member older *Benefits for are provided on the You may have to pay covered services allowed charge. any amount over the (See Parts 2 and 9.) allowed charge. (continued) Routine Tests
Outpatient treatment: Full benefits less the Part B deductible and Part B coinsurance (Nothing for services not covered by Medicare) Outpatient treatment: The Part B deductible and Part B coinsurance for as many visits as are medically necessary for Medicare and covered services; and full benefits when covered by Medex only for up to 24 visits per calendar year Outpatient treatment: Nothing for Medicare and Medex covered services for as many visits as are medically necessary; and nothing for up to 24 visits per calendar year for services covered by Medex only; then all charges 26 Physical Therapist Services Full benefits less the Part B deductible and Part B coinsurance for Medicare approved physical therapy The Part B deductible and Part B coinsurance for Medicare approved physical therapy Nothing for Medicare approved physical therapy 26 Podiatry Care Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 26 Radiation and X-Ray Therapy Full benefits less the Part B deductible and Part B coinsurance The Part B deductible and Part B coinsurance Nothing 27 Routine Tests For routine mammograms: Full benefits less the Part B coinsurance (the Part B deductible does not apply) for one baseline mammogram between age 35 through 39 and one routine mammogram per year for a member age 40 or older For routine mammograms: The Part B coinsurance (the Part B deductible does not for one baseline mammogram between age 35 through 39 and one routine mammogram per year for a member age 40 or older For routine mammograms: Nothing for one baseline mammogram between age 35 through 39; and one routine mammogram per year for a member age 40 or older 27 *Benefits for covered services are provided on the allowed charge. You may have to pay any amount over the allowed charge. (See Parts 2 and 9.) Routine Tests (continued)
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