Page 5 - Summary of Benefits_PPO_H2406-010_2019
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AARP® MedicareComplete Choice® (PPO)
dummy spacing In-Network Out-of-Network
Benefits
Inpatient Hospital $295 copay per day: for $495 copay per day: for
days 1-4 days 1-21
$0 copay per day: for $0 copay per day: for
days 5 and beyond days 22 and beyond
Our plan covers an unlimited number of days for an
inpatient hospital stay.
Outpatient Hospital Type 1 facility: $150 40% coinsurance
copay, Type 2 facility:
$275 copay Cost sharing for
additional plan covered
Cost sharing for services will apply.
additional plan covered
services will apply.
Outpatient Hospital Observation $275 copay 40% coinsurance
Services
Doctor Visits Primary $10 copay $45 copay
Specialists $35 copay $70 copay
Preventive Care Medicare-covered $0 copay $0 copay - 40%
coinsurance (depending
on the service)
Abdominal aortic aneurysm screening
Alcohol misuse counseling
Annual “Wellness” visit
Bone mass measurement
Breast cancer screening (mammogram)
Cardiovascular disease (behavioral therapy)
Cardiovascular screening
Cervical and vaginal cancer screening
Colorectal cancer screenings (colonoscopy, fecal
occult blood test, flexible sigmoidoscopy)
Depression screening
Diabetes screenings and monitoring
Hepatitis C screening
HIV screening
Lung cancer with low dose computed tomography
(LDCT) screening
Medical nutrition therapy services
dummy spacing In-Network Out-of-Network
Benefits
Inpatient Hospital $295 copay per day: for $495 copay per day: for
days 1-4 days 1-21
$0 copay per day: for $0 copay per day: for
days 5 and beyond days 22 and beyond
Our plan covers an unlimited number of days for an
inpatient hospital stay.
Outpatient Hospital Type 1 facility: $150 40% coinsurance
copay, Type 2 facility:
$275 copay Cost sharing for
additional plan covered
Cost sharing for services will apply.
additional plan covered
services will apply.
Outpatient Hospital Observation $275 copay 40% coinsurance
Services
Doctor Visits Primary $10 copay $45 copay
Specialists $35 copay $70 copay
Preventive Care Medicare-covered $0 copay $0 copay - 40%
coinsurance (depending
on the service)
Abdominal aortic aneurysm screening
Alcohol misuse counseling
Annual “Wellness” visit
Bone mass measurement
Breast cancer screening (mammogram)
Cardiovascular disease (behavioral therapy)
Cardiovascular screening
Cervical and vaginal cancer screening
Colorectal cancer screenings (colonoscopy, fecal
occult blood test, flexible sigmoidoscopy)
Depression screening
Diabetes screenings and monitoring
Hepatitis C screening
HIV screening
Lung cancer with low dose computed tomography
(LDCT) screening
Medical nutrition therapy services
