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Providence Health Plan is a health plan with a Medicare contract. - page 14 / 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.

PREVENTIVE SERVICES (continued)

26 - Pap Smears and Pelvic Exams

No coinsurance, copayment, or deductible for Pap smears.

(for women with Medicare)

No coinsurance, copayment, or deductible for Pelvic and clinical breast exams.

Covered once every 2 years. Covered once a year for women with Medicare at high risk.

27 - Prostate Cancer Screening Exams

20% coinsurance for the digital rectal exam.

(for men with Medicare age 50 and older)

$0 for the PSA test; 20% coinsurance for other related services.

Covered once a year for all men with Medicare over age 50.

28 - End-Stage Renal Disease

20% coinsurance for renal dialysis

See page 26 for additional information about End- Stage Renal Disease.

20% coinsurance for Nutrition Therapy for End-Stage Renal Disease

Nutrition therapy is for people who have diabetes or kidney disease (but aren't on dialysis or haven't had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease.

Benefit Category

Original Medicare

Providence Medicare Extra + RX

In-Network

$0 copay for Medicare-covered pap smears and pelvic exams

up to 1 additional pap smear(s) and pelvic exam(s) every year

Separate Office Visit cost sharing of $15 may apply.

In-Network $0 copay for:

Medicare-covered prostate cancer screening.

Separate Office Visit cost sharing of $15 may apply.

General Authorization rules may apply.

In-Network $0 copay for renal dialysis.

$0 copay for Nutrition Therapy for End-Stage Renal Disease.

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