Plan Specifics | You Pay (In-Network Costs) | |
---|---|---|
Plan-year deductible | $0 | |
Plan-year out-of-pocket maximum | $3,400 in-network or $5,100 for the combined in- and out-of-network medical services—this is the maximum out-of-pocket amount you pay each year for Medicare-covered services | |
Benefit | You Pay | |
Preventive care, routine physicals, GYN, well child, routine hearing and vision exams, family planning | Nothing | |
Office visits (sick care/ non-preventive) | $25 per visit | |
Emergency room | $65 per visit, waived if admitted within 24 hours | |
Inpatient hospital care | $150 per day for 1–5 days $0 per day after 5 days $750 annual out-of-pocket limit |
|
Outpatient surgery | $100 per visit | |
CT scans, MRIs, and other imaging tests | $100 per day for CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $0 for X-rays and other diagnostic tests |