Page 12 - ITDR Benefits & Resources guide 2019

MEDICAL P
LAN
SUMMARY OF BENEFITS
SUPPLEMENT-TYPE PLAN
MEDICARE ADVANTAGE STANDARD PLAN
MEDICARE ADVANTAGE ENHANCED PLAN
YOU PAY
CALENDAR YEAR DEDUCTIBLE
$300
Only applies to Part B services, and must be satisfied before any Medicare Part B benefits are paid by Anthem. The Medicare Part B deductible is included in this $300 calendar year deductible.
Note: Plan pays entire Medicare Part A deductible; member pays $0 of Medicare Part A deductible.
$750
Deductible applies to Part
A and Part B covered services as noted within each category below, prior to the copay or coinsurance, if any, being applied.
$0
MAXIMUM ANNUAL OUT OF POCKET
$1,500
Only applies to Part B services. All Part B coinsurance and deductible amounts accrue towards the medical plan maximum annual out-of-pocket amount, with the exception of the foreign travel emergency and urgently needed care deductible or coinsurance amounts.
$2,500
All copays, coinsurance, and deductible amounts accrue towards the medical plan maximum annual out-of-pocket amount,
with the exception of the foreign travel emergency and urgently needed care deductible or coinsurance amounts.
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