Page 6 - Summary of Benefits_MA_RPPO_7444-004
P. 6
Benefits In-Network Out-of-Network
Obesity screenings and counseling
Prostate cancer screenings (PSA)
Sexually transmitted infections screenings and
counseling
Tobacco use cessation counseling (counseling for
people with no sign of tobacco-related disease)
Vaccines, including flu shots, hepatitis B shots,
pneumococcal shots
“Welcome to Medicare” preventive visit (one-time)
Any additional preventive services approved by
Medicare during the contract year will be covered.
This plan covers preventive care screenings and
annual physical exams at 100% when you use in-
network providers.
Routine physical $0 copay; 1 per year* 40% coinsurance; 1 per
year*
Emergency Care $90 copay (worldwide) per visit
If you are admitted to the hospital within 24 hours,
you pay the inpatient hospital copay instead of the
Emergency copay. See the “Inpatient Hospital Care”
section of this booklet for other costs.
Urgently Needed Services $30 - $40 copay
Diagnostic Tests, Diagnostic 20% coinsurance 40% coinsurance
Lab and radiology services
Radiology (e.g. MRI) $2 copay $2 copay
Services, and X- 20% coinsurance 40% coinsurance
Rays Lab services
Diagnostic tests
and procedures
Therapeutic 20% coinsurance 40% coinsurance
Radiology
Outpatient X-rays $14 copay per service $21 copay per service
Obesity screenings and counseling
Prostate cancer screenings (PSA)
Sexually transmitted infections screenings and
counseling
Tobacco use cessation counseling (counseling for
people with no sign of tobacco-related disease)
Vaccines, including flu shots, hepatitis B shots,
pneumococcal shots
“Welcome to Medicare” preventive visit (one-time)
Any additional preventive services approved by
Medicare during the contract year will be covered.
This plan covers preventive care screenings and
annual physical exams at 100% when you use in-
network providers.
Routine physical $0 copay; 1 per year* 40% coinsurance; 1 per
year*
Emergency Care $90 copay (worldwide) per visit
If you are admitted to the hospital within 24 hours,
you pay the inpatient hospital copay instead of the
Emergency copay. See the “Inpatient Hospital Care”
section of this booklet for other costs.
Urgently Needed Services $30 - $40 copay
Diagnostic Tests, Diagnostic 20% coinsurance 40% coinsurance
Lab and radiology services
Radiology (e.g. MRI) $2 copay $2 copay
Services, and X- 20% coinsurance 40% coinsurance
Rays Lab services
Diagnostic tests
and procedures
Therapeutic 20% coinsurance 40% coinsurance
Radiology
Outpatient X-rays $14 copay per service $21 copay per service
