Outline of Coverage - Premera Blue Cross

NPLAN N (continued):MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR*Once you have been billed $147 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.SERVICESMEDICAREPAYSPLAN N PAYSYOU PAYMEDICAL EXPENSESIn or out of the Hospital and Outpatient Hospital Treatment, such as physician's services, inpatientand outpatient medical and surgical services and supplies, physical and speech therapy, diagnostictests, durable medical equipment.First $147 of Medicare approvedamounts*Remainder of Medicare approvedamountsPart B Excess Charges(above Medicare approved amounts)BLOOD$0 $0Generally 80%Balance, otherthan up to $20 peroffice visit and upto $50 peremergency roomvisit. Thecopayment of up to$50 is waived if themember isadmitted to anyhospital and theemergency visit iscovered as aMedicare Part Aexpense$147(Part B Deductible)Up to $20 peroffice visit and upto $50 peremergency roomvisit. Thecopayment of upto $50 is waivedif the member isadmitted to anyhospital and theemergency visitis covered as aMedicare Part Aexpense$0 $0 All costsFirst 3 pints $0 All costs $0Next $147 of Medicare approvedamounts*Remainder of Medicare approvedamountsCLINICAL LABORATORY SERVICES$0 $0$147(Part B Deductible)80% 20% $0Tests for diagnostic services 100% $0 $013