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Providence Health Plan is a health plan with a Medicare contract. - page 10 / 32

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SUMMARY OF BENEFITS

If you have any questions about this plan’s benefits or costs, please contact Providence Health Plan.

Benefit Category OUTPATIENT CARE (continued)

Original Medicare

Providence Medicare Extra + RX

15 - Emergency Care

(You may go to any emergency room if you

20% coinsurance for the doctor

Specified copayment for

General

$50 copay for Medicare-covered emergency room visits.

reasonably believe you need outpatient hospital emergency

emergency care)

room (ER) facility charge.

ER Copay cannot exceed Part A inpatient hospital deductible.

Worldwide coverage.

If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the emergency room visit.

You don't have to pay the emergency room copay if you are admitted to the hospital for the same condition within 3 days of the emergency room visit.

NOT covered outside the U.S. except under limited circumstances.

16 - Urgently Needed Care

(This is NOT emergency care, and in most cases, is out of the service area)

See page 26 for additional information about Urgently Needed Care.

20% coinsurance, or a set copay

NOT covered outside the U.S. except under limited circumstances.

General

$25 copay for Medicare-covered urgently needed care visits.

If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the urgently-needed care visit.

17 - Outpatient Rehabilitation Services

20% coinsurance

General Authorization rules may apply.

(Occupational Therapy, Physical Therapy, Speech and Language Therapy, Respiratory Therapy Services, Social/Psychological Services, and more)

In-Network $15 copay for Medicare-covered Occupational Therapy visits.

$15 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.

$15 copay for Medicare-covered Cardiac Rehab services.

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