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Providence Health Plan is a health plan with a Medicare contract. - page 13 / 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 PREVENTIVE SERVICES

Original Medicare

Providence Medicare Extra + RX

22 - Bone Mass Measurement

No coinsurance, copayment o deductible.

(for people with Medicare who are at risk)

Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions.

r In-Network $0 copay for Medicare-covered bone mass measurement.

Separate Office Visit cost sharing of $15 may apply.

23 - Colorectal Screening Exams

No coinsurance, copayment o deductible for screening colonoscopy or screening flexible sigmoidoscopy.

(for people with Medicare age 50 and older)

See page 26 for additional information about Colorecta Screening Exams.

Covered when you are high l risk or when you are age 50 and older.

r In-Network $0 copay for Medicare-covered colorectal screenings.

Separate Office Visit cost sharing of $15 may apply.

25 - Mammograms (Annual Screening)

No coinsurance, copayment or deductible.

(for women with Medicare age 40 and older)

No referral needed.

Covered once a year for all women with Medicare age 40 and older. One baseline mammogram covered for women with Medicare between age 35 and 39.

Separate Office Visit cost sharing of $15 may apply.

$0 copay for Medicare-covered screening mammograms.

In-Network

Referral needed for other immunizations.

Separate Office Visit cost sharing of $15 may apply.

24 - Immunizations

(Flu vaccine, Hepatitis B vaccine - for people with Medicare who are at risk, Pneumonia vaccine)

See page 26 for additional information about Immunizations.

No referral needed for Flu and pneumonia vaccines.

$0 copay for Flu, Pneumonia, and Hepatitis B vaccines.

General Authorization rules may apply.

You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information.

In-Network $0 copay for Flu and Pneumonia vaccines.

$0 copay for Hepatitis B vaccine..

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