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| If You Have Medicare Part A (Hospital Insurance) |
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| Medicare Pays: |
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What You Have To Pay: |
First 60 days of a hospital stay each benefit period
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The first $992 of the hospital bill - known as the Medicare Part A deductible
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61st through 90th day each benefit period
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$248 per day during this time
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60 Lifetime Reserve days
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$496 per day during this time
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Up to 210 days of hospice care
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$5 for outpatient drugs and 5% of the cost for inpatient respite care up to the amount of the inpatient hospital deductible
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Nothing for inpatient hospital care outside the U.S. (with rare exceptions)
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All charges
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For up to 190 days (lifetime limit) of inpatient mental health/substance abuse care
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The $992 hospital deductible and the charges after you've used up the 190 lifetime days
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For up to 100 days of skilled nursing facility care following a hospital stay
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$124 per day for the 21st through the 100th day of care
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When You Have Medicare Part A (Hospital Insurance) And Medicare Pays Primary Benefits, This Is What You Pay When You Also Have Service Benefit Plan Coverage:
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What You Have To Pay: |
| Medicare Gaps: |
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Standard Option: |
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Basic Option: |
The inpatient hospital deductible of $992 for the first 60 inpatient days
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Nothing for covered services
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Nothing for covered services
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Your $248 daily share of the inpatient hospital bill from the 61st day through 90th day
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Nothing for covered services
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Nothing for covered services
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After the 90th day:
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If you use your 60 lifetime reserve days, you pay $496 of the daily cost
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Nothing for covered services
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Nothing for covered services
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If you elect to save your 60 lifetime reserve days
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Nothing for covered services
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Nothing for covered services
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After you have used all of your Medicare Part A benefits,** including your 60 lifetime reserve days, Medicare benefits end.
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When all your inpatient Medicare benefits end,** nothing for covered services in Preferred network and Member hospitals. In Non-member hospitals, you are usually responsible for the difference between the facility's Billed charge and our allowance.***
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When your inpatient Medicare benefits end,** $100 per day copayment up to $500
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5% coinsurance for inpatient respite hospice care costs and copayments of $5 for prescription drugs
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When Prior Approval is obtained, nothing for covered services applied to the Medicare coinsurance and prescription drug copayment/
coinsurance amounts when billed by the home health care agency
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When Prior Approval is obtained, nothing for covered services applied to the Medicare coinsurance and prescription drug copayment/
coinsurance amounts when billed by the home health care agency
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All charges for inpatient hospital care outside the U.S.
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Nothing for covered services
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Nothing for covered services
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The inpatient hospital deductible of $992 and your share of the hospital bill for inpatient mental health/substance abuse care
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Nothing for covered services for inpatient hospital expenses
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Nothing for covered services for inpatient hospital expenses
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Your $124 daily share of the bill for skilled nursing facility care from the 21st day through the 100th day
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Nothing for the 21st through the 30th day of your confinement. You are responsible for the daily share after the 30th day.
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This is not a benefit. You pay all charges.
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If You Have Medicare Part A Only (Hospital Insurance), You Have No Medical Coverage And You Are Responsible For All Outpatient Hospital And Physician Charges. If You Add Blue Cross and Blue Shield Service Benefit Plan Coverage, You Do Have Coverage For These Services. Here's What You Pay For Care Rendered By Preferred Network Providers:
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What You Have To Pay: |
| Medicare Gaps: |
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Standard Option: |
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Basic Option: |
Hospital/Facility charges for:
Outpatient surgery
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10% of the Plan Allowance***
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$40 copayment per day
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Hospital/Facility charges for:
Outpatient physical speech, and occupational therapy (visit maximums apply)
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$15 copayment per visit
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$20 copayment per visit
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Hospital charges for:
Diagnostic tests**
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10% of the Plan Allowance*** and the $250 annual deductible
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Nothing for covered services
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Emergency room charges for accidental injury care
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Nothing for covered services within 72 hours of the injury
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$50 copayment for emergency room care
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Physicians' charges for:
Hospital inpatient visits
Inpatient and outpatient surgery
Outpatient laboratory services**
Outpatient X-rays**
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10% of the Preferred Provider Allowance (PPA)***, after you meet the $250 annual deductible
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Hospital inpatient visits:
Nothing for covered services
Inpatient and outpatient surgery:
$100 copayment per surgeon
Outpatient laboratory services and X-rays:
Nothing when billed by your doctor
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Durable medical equipment (DME)
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10% of the Plan allowance after you meet the $250 annual deductible
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30% of the Plan allowance for DME
$50 copayment for ambulance services
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Ambulance services
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$50 copayment
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$50 copayment
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Physician home and office visits, and outpatient physical, speech and occupational therapy (visit maximums apply)
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$15 per visit
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$20 copayment per visit for primary care physician, $30 copayment per visit for specialists
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Prescription drugs**** including:
Insulin
Disposable syringes
Diabetic diagnostic supplies
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Mail Service
Pharmacy:
$10 for generic
drugs and $35 for
brand name drugs
for each
prescription
or refill
Retail Pharmacy Program:
You pay 25% of the Preferred Provider Allowance (PPA)****
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Mail Service
Pharmacy:
Not a benefit
Retail Pharmacy Program:
$10 copayment for generic drugs, $30 copayment for formulary brand name drugs, and 50% ($35 minimum) for non-formulary Non-preferred brand name drugs
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Routine or preventive dental care*****
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You are responsible for the difference between the dental fee schedule allowance and the Maximum Allowable Charge (MAC)
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$20 copayment for each evaluation, 2 exams and cleanings per year, annual X-rays
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