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Providence Health Plan is a health plan with a Medicare contract. - page 12 / 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

Original Medicare

Providence Medicare Extra + RX

OUTPATIENT MEDICAL SERVICES AND SUPPLIES (continued)

21 - Diagnostic Tests, X-Rays, and Lab Services

20% coinsurance for Diagnostic Tests and X-rays

and Radiology Services

$0 copay for Medicare- covered lab services

Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most routine screening tests, like checking your cholesterol.

General Authorization rules may apply.

In-Network $0 copay for Medicare-covered: lab services

diagnostic procedures and tests

10% of the cost for Medicare- covered X-rays.

10% of the cost for Medicare- covered Diagnostic Radiology Services (not including X-rays).

10% of the cost for Medicare- covered Therapeutic Radiology Services.

Separate Office Visit cost sharing of $15 may apply for Outpatient

Diagnostic Procedures, Tests and Lab Services.

Separate Office Visit cost sharing of $15 may apply for Outpatient Diagnostic and Therapeutic Radiological Services.

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