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Providence Health Plan is a health plan with a Medicare contract. - page 8 / 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.

7 - Hospice

You pay part of the cost for

General

See page 26 for additional information about Hospice.

outpatient drugs and inpatient respite care.

You must get care from a Medicare- certified hospice.

Providence Medicare Extra + RX

OUTPATIENT CARE 8 - Doctor Office Visits

Benefit Category INPATIENT CARE (continued)

Original Medicare

You must get care from a Medicare-certified hospice.

20% coinsurance.

General

See "Welcome to Medicare; and Annual Wellness Visit", for more information.

In-Network $15 copay for each primary care doctor visit for Medicare-covered benefits.

$25 copay for each in-area, network urgent care Medicare-covered visit.

$15 copay for each specialist visit for Medicare-covered benefits.

9 - Chiropractic Services

Routine care not covered

20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

In-Network $15 copay for each Medicare- covered visit.

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

10 - Podiatry Services

Routine care not covered. 20% coinsurance for medicall

In-Network y $15 copay for each Medicare-

necessary foot care, including care for medical conditions affecting the lower limbs.

covered visit.

Medicare-covered podiatry benefits are for medically-necessary foot care.

8

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