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Providence Health Plan is a health plan with a Medicare contract. - page 9 / 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.

11 - Outpatient Mental

45% coinsurance for most

Health Care

outpatient mental health

services.

Providence Medicare Extra + RX

General Authorization rules may apply.

Benefit Category OUTPATIENT CARE (continued)

Original Medicare

In-Network

$15 copay for each Medicare- covered individual or group therapy visit

12 - Outpatient Substance 20% coinsurance Abuse Care

General Authorization rules may apply.

In-Network

$15 copay for Medicare-covered individual or group visits

13 - Outpatient Services/Surgery

20% coinsurance for the doctor

General Authorization rules may apply.

Specified copayment for outpatient hospital facility charges. Copay cannot exceed the Part A inpatient hospital deductible.

In-Network

$100 copay for each Medicare- covered ambulatory surgical center visit.

20% coinsurance for ambulatory surgical center facility charges

$100 copay for each Medicare- covered outpatient hospital facility visit.

14 - Ambulance Services

20% coinsurance

In-Network

(medically necessary ambulance services)

$100 copay for Medicare-covered ambulance benefits.

See page 26 for additional information about Ambulance services.

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