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SERVICES
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MEDICARE PAYS
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PLAN C PAYS
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YOU PAY
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Medical Expenses-In Or Out Of 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:
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• First $155 of Medicare-Approved Amounts*
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$0
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$155 (Part B Deductible)
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$0
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• Remainder of Medicare-Approved Amounts
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Generally 80%
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Generally 20%
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$0
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Part B Excess Charges – (Above Medicare-Approved Amounts)
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$0
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$0
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All costs
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Blood
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• First 3 pints
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$0
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All costs
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$0
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• Next $155 of Medicare-Approved Amounts*
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$0
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$155 (Part B Deductible)
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$0
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• Remainder of Medicare-Approved Amounts
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80%
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20%
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$0
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Clinical Laboratory Services
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• Tests for diagnostic services
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100%
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$0
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$0
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Medicare Parts A and B
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Home Health CareMedicare-Approved Services
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• Medically necessary skilled care services and medical supplies
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100%
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$0
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$0
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• Durable medical equipment
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— First $155 of Medicare-Approved Amounts*
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$0
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$155 (Part B Deductible)
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$0
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— Remainder of Medicare-Approved Amounts
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80%
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20%
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$0
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Other Benefits Not Covered by Medicare
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Foreign Travel-Not Covered by Medicare – Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA
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• First $250 each calendar year
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$0
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$0
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$250
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• Remainder of charges
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$0
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80% to a lifetime maximum benefit of $50,000
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20% and amounts over the $50,000 lifetime maximum
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