Page 9 - Cover Letter and Medicare Evaluation for Vic Bosiger

Optima AARP Medicare HumanaChoice
Medicare Value Advantage H5216-248

(HMO) Plan 1 (HMO- (PPO)

$0.00 POS) $0.00

Medicare Advantage and $0.00 Medicare Advantage and
drug monthly premium Medicare Advantage and drug monthly premium

drug monthly premium
Diagnostic tests & $0-85 copay In-network: $20 copay In-network: $0-85
procedures copay

Out-of-network: $0

copay or 40%
coinsurance

Lab services $0 copay In-network: $0 copay In-network: $0-50

copay
Out-of-network: 40%
coinsurance

Diagnostic radiology $0-275 copay In-network: $0-160 In-network: $35-275
services (like MRI) copay copay

Out-of-network: 40%
coinsurance

Outpatient x-rays $0-85 copay In-network: $15 copay In-network: $0-105

copay
Out-of-network: 40%

coinsurance

Emergency care $90 copay per visit $90 copay per visit $90 copay per visit

(always covered) (always covered) (always covered)

Urgent care $25 copay per visit $40 copay per visit $0-35 copay or 40%

(always covered) (always covered) coinsurance per visit
(always covered)

Inpatient hospital $275 per day for days 1 In-network: $295 per In-network: $355 per
coverage through 6 day for days 1 through 6 day for days 1 through 4

$0 per day for days 7 $0 per day for days 7 $0 per day for days 5
through 90 through 90 through 90

$0 per day for days 91 $0 per day for days 91
and beyond and beyond
Out-of-network: Not Out-of-network: 40%

Applicable per stay