Page 16 - ITDR Benefits & Resources guide 2019

MEDICAL P
LAN
SUPPLEMENT-TYPE PLAN
MEDICARE ADVANTAGE STANDARD PLAN
MEDICARE ADVANTAGE ENHANCED PLAN
DIAGNOSTIC SERVICES/LABS/IMAGING
For Medicare-covered services. Deductible applies to all services with coinsurance or copays under the Supplement-Type Plan and Medicare Advantage Standard Plan, unless otherwise stated.
For the Medicare Advantage Standard Plan and the Medicare Advantage Enhanced Plan, your provider must obtain approval from the plan before you get complex imaging, as well as limited diagnostic and therapeutic radiology services, including but not limited to, radiation therapy, PET, CT, SPECT, MRI scans, echocardiograms, diagnostic laboratory tests, genetic testing, sleep studies, and related sleep study equipment and supplies. This is called getting prior authorization.
The plan pays 100% for the first 3 pints of blood, then Medicare pays 100%.
Clinical lab services, blood tests, urinalysis: $0 copay.
$40 copay for each X-ray visit and/or simple diagnostic test.
10% coinsurance for each X-ray visit and/or simple diagnostic test.
$40 copay for each radiation therapy treatment.
$0 copay for testing to confirm chronic obstructive pulmonary disease. Deductible does not apply.
$25 copay for each radiation therapy treatment.
$0 copay for testing to confirm chronic obstructive pulmonary disease.
10% coinsurance for complex diagnostic test and/or radiology visit. 10% coinsurance for supplies.
$0 copay for each clinical/diagnostic lab test.
$0 copay per pint of blood.
Deductible does not apply.
$0 copay per pint of blood.
TRANSPORTATION (MEDICALLY NECESSARY)
Deductible applies to all services with coinsurance under the Supplement-Type Plan.
10% coinsurance.
Non-emergency transportation must be medically necessary and supported by written order from doctor.
Non-emergency transportation is covered at 10% coinsurance with prior authorization from the plan.
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