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Providence Health Plan is a health plan with a Medicare contract. - page 5 / 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 IMPORTANT INFORMATION

Original Medicare

Providence Medicare Extra + RX

1 - Premium and Other Important Information

In 2010 the monthly Part B Premium was $96.40 and may change for 2011 and the yearly Part B deductible amount was $155 and may change for 2011.

If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more.

Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800- 325-0778.

General $128 monthly plan premium in addition to your monthly Medicare Part B premium.

Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B and Part D premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

This plan covers all Medicare-covered preventive services with zero cost sharing.

In-Network $2,500 out-of-pocket limit.

All plan services included.

2 - Doctor and Hospital Choice

(For more information, see Emergency Care - #15 and Urgently Needed Care - #16)

You may go to any doctor, specialist or hospital that accepts Medicare.

In-Network

You must go to network doctors, specialists, and hospitals.

Referral required for network hospitals and specialists (for certain benefits).

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