[29 Pa.B. 172]

[Continued from previous Web Page]

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE APPROVED SERVICES    --  Medically necessary skilled care services and medical supplies    --  Durable medical equipment         First $100 of Medicare approved            amounts*         Remainder of Medicare approved            amounts   AT-HOME RECOVERY SERVICES--NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a home care treatment plan    --  Benefit for each visit    --  Number of visits covered (must be received within 8 weeks of last Medicare approved visit)    --  Calendar year maximum	100%     $0   80%                 $0 $0     $0	$0     $0   20%               Actual charges to $40 a visit Up to the number of Medicare approved visits, not to exceed 7 each week $1,600	$0     $100 (Part B deductible)   $0                 Balance

OTHER BENEFITS--NOT COVERED BY MEDICARE

FOREIGN TRAVEL--NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA    First $250 each calendar year Remainder of charges

$0 $0

$0 80% to a lifetime maximum benefit of $50,000

$250 20% and amounts over the $50,000 life-time maximum

PLAN E

MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies    First 60 days    61st thru 90th day    91st day and after:    --  While using 60 lifetime reserve days    --  Once lifetime reserve days are used:         --  Additional 365 days         --  Beyond the additional 365 days	All but $760 All but $190 a day     All but $380 a day   $0 $0	$760 (Part A deductible) $190 a day     $380 a day 100% of Medicare eligible expenses $0	$0 $0     $0   $0 All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital    First 20 days    21st thru 100th day    101st day and after	All approved amounts All but $95 a day $0	$0 Up to $95 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

PLAN E

MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR

*Once you have been billed $100 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES-- IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,    First $100 of Medicare approved       amounts*    Remainder of Medicare approved       amounts    Part B excess charges (Above Medicare       approved amounts)	$0   80% (50% outpatient psychiatric services) $0	$0   20% (50% outpatient psychiatric services) $0	$100 (Part B deductible)   $0   All costs
BLOOD First 3 pints Next $100 of Medicare approved    amounts* Remainder of Medicare approved    amounts	$0 $0   80%	All costs $0   20%	$0 $100 (Part B deductible)   $0
CLINICAL LABORATORY SERVICES--BLOOD TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PARTS A & B

HOME HEALTH CARE MEDICARE APPROVED SERVICES    --  Medically necessary skilled care services and medical supplies    --  Durable medical equipment         First $100 of Medicare approved            amounts*         Remainder of Medicare approved            amounts	100%     $0   80%	$0     $0   20%	$0     $100 (Part B deductible)   $0

OTHER BENEFITS--NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
FOREIGN TRAVEL--NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA    First $250 each calendar year Remainder of charges	$0 $0	$0 80% to a lifetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 life-time maximum
PREVENTIVE MEDICARE CARE BENEFIT--NOT COVERED BY MEDICARE Some physical and preventive tests and services such as: digital rectal exam, hearing screening, dipstick urinalysis, diabetes screening, thyroid function test, tetanus and diphtheria booster and education, administered or ordered by your doctor when not covered by Medicare    First $120 each calendar year    Additional charges	$0 $0	$120 $0	$0 All costs

PLAN F or HIGH DEDUCTIBLE PLAN F

MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
**This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year [$1,500] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are [$1,500]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.

SERVICES	MEDICARE PAYS	AFTER YOU PAY $1,500 DEDUCTIBLE,** PLAN PAYS	IN ADDITION TO $1,500 DEDUCTIBLE,** YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies    First 60 days    61st thru 90th day    91st day and after:    --  While using 60 lifetime reserve days    --  Once lifetime reserve days are used:         --  Additional 365 days         --  Beyond the additional 365 days	All but $760 All but $190 a day   All but $380 a day       $0 $0	$760 (Part A deductible) $190 a day   $380 a day     100% of Medicare eligible expenses $0	$0 $0   $0       $0 All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital    First 20 days    21st thru 100th day    101st day and after	All approved amounts All but $95 a day $0	$0 Up to $95 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR

*Once you have been billed $100 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
**This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year [$1,500] deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are [$1,500]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.

SERVICES	MEDICARE PAYS	AFTER YOU PAY $1,500 DEDUCTIBLE,** PLAN PAYS	IN ADDITION TO $1,500 DEDUCTIBLE,** YOU PAY
MEDICAL EXPENSES-- IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,    First $100 of Medicare approved       amounts*    Remainder of Medicare approved       amounts    Part B excess charges (Above Medicare       approved amounts)	$0   80% (50% outpatient psychiatric service) $0	$100 (Part B deductible)   20% (50% outpatient psychiatric service) 100%	$0   $0   $0
BLOOD First 3 pints Next $100 of Medicare approved    amounts* Remainder of Medicare approved    amounts	$0 $0   80%	All costs $100 (Part B deductible)   20%	$0 $0   $0
CLINICAL LABORATORY SERVICES--BLOOD TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PARTS A & B

HOME HEALTH CARE MEDICARE APPROVED SERVICES    --  Medically necessary skilled care services and medical supplies    --  Durable medical equipment         First $100 of Medicare approved            amounts*         Remainder of Medicare approved            Amounts	100%     $0   80%	$0     $100 (Part B deductible)   20%	$0     $0   $0

OTHER BENEFITS--NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	AFTER YOU PAY $1,500 DEDUCTIBLE,** PLAN PAYS	IN ADDITION TO $1,500 DEDUCTIBLE,** YOU PAY
FOREIGN TRAVEL--NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA    First $250 each calendar year Remainder of charges	$0 $0	$0 80% to a lifetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 life-time maximum

PLAN G

MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies    First 60 days    61st thru 90th day    91st day and after:    --  While using 60 lifetime reserve days    --  Once lifetime reserve days are used:         --  Additional 365 days         --  Beyond the additional 365 days	All but $760 All but $190 a day     All but $380 a day   $0 $0	$760 (Part A deductible) $190 a day     $380 a day 100% of Medicare eligible expenses $0	$0 $0     $0   $0 All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital    First 20 days    21st thru 100th day    101st day and after	All approved amounts All but $95 a day $0	$0 Up to $95 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR

*Once you have been billed $100 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES-- IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,    First $100 of Medicare approved       amounts*    Remainder of Medicare approved       amounts    Part B excess charges (Above Medicare       approved amounts)	$0   80% (50% outpatient psychiatric services) $0	$0   20% (50% outpatient psychiatric services) 80%	$100 (Part B deductible)   $0   20%
BLOOD First 3 pints Next $100 of Medicare approved    amounts* Remainder of Medicare approved    amounts	$0 $0   80%	All costs $0   20%	$0 $100 (Part B deductible)   $0
CLINICAL LABORATORY SERVICES--BLOOD TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PARTS A & B

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOME HEALTH CARE MEDICARE APPROVED SERVICES    --  Medically necessary skilled care services and medical supplies    --  Durable medical equipment         First $100 of Medicare approved            amounts*         Remainder of Medicare approved            amounts   AT-HOME RECOVERY SERVICES-NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a home care treatment plan    --  Benefit for each visit    --  Number of visits covered (must be received within 8 weeks of last Medicare approved visit)    --  Calendar year maximum	100%     $0   80%                 $0 $0     $0	$0     $0   20%               Actual charges to $40 a visit Up to the number of Medicare approved visits, not to exceed 7 each week $1,600	$0     $100 (Part B deductible)   $0                 Balance

OTHER BENEFITS--NOT COVERED BY MEDICARE

FOREIGN TRAVEL--NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA    First $250 each calendar year Remainder of charges

$0 $0

$0 80% to a lifetime maximum benefit of $50,000

$250 20% and amounts over the $50,000 life-time maximum

PLAN H

MEDICARE (PART A)--HOSPITAL SERVICES--PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies    First 60 days    61st thru 90th day    91st day and after:    --  While using 60 lifetime reserve days    --  Once lifetime reserve days are used:         --  Additional 365 days         --  Beyond the additional 365 days	All but $760 All but $190 a day     All but $380 a day   $0 $0	$760 (Part A deductible) $190 a day     $380 a day 100% of Medicare eligible expenses $0	$0 $0     $0   $0 All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital    First 20 days    21st thru 100th day    101st day and after	All approved amounts All but $95 a day $0	$0 Up to $95 a day $0	$0 $0 All costs
BLOOD First 3 pints Additional amounts	$0 100%	3 pints $0	$0 $0
HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

MEDICARE (PART B)--MEDICAL SERVICES--PER CALENDAR YEAR

*Once you have been billed $100 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES-- IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment,    First $100 of Medicare approved       amounts*    Remainder of Medicare approved       amounts    Part B excess charges (Above Medicare       approved amounts)	$0   80% (50% outpatient psychiatric services) $0	$0   20% (50% outpatient psychiatric services) $0	$100 (Part B deductible)   $0   All costs
BLOOD First 3 pints Next $100 of Medicare approved    amounts* Remainder of Medicare approved    amounts	$0 $0   80%	All costs $0   20%	$0 $100 (Part B deductible)   $0
CLINICAL LABORATORY SERVICES--BLOOD TESTS FOR DIAGNOSTIC SERVICES	100%	$0	$0

PARTS A & B

HOME HEALTH CARE MEDICARE APPROVED SERVICES    --  Medically necessary skilled care services and medical supplies    --  Durable medical equipment         First $100 of Medicare approved            amounts*         Remainder of Medicare approved            amounts	100%     $0   80%	$0     $0   20%	$0     $100 (Part B deductible)   $0

OTHER BENEFITS--NOT COVERED BY MEDICARE

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
FOREIGN TRAVEL--NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA    First $250 each calendar year    Remainder of charges	$0 $0	$0 80% to a lifetime maximum benefit of $50,000	$250 20% and amounts over the $50,000 life-time maximum
BASIC OUTPATIENT PRE- SCRIPTION DRUGS--NOT COVERED BY MEDICARE First $250 each calendar year Next $2,500 each calendar year   Over $2,500 each calendar year	$0 $0   $0	$0 50%--$1,250 calendar year maximum benefit $0	$250 50%   All costs

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