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