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Monthly Premium, Deductible and Limits Monthly Plan ■ $284.50 Premium You must continue to pay your Medicare Part B premium. Deductible ■ $0 per year for In -Network health care services • $2,000 per year for Out -of -Network health care services ■ $0 per year for Part D prescription drugs Maximum ■ $1,000 is the most you pay for copays, coinsurance and other costs for Out -of -Pocket Medicare -covered medical services from in -network providers for the year. Responsibility . $3,000 is the most you pay for copays, coinsurance and other costs for Medicare -covered medical services you receive from in- and out -of -network providers. Medical and Hospital Benefits In -Network Out -of -Network Inpatient ■ $200 copay per day for days 1-7 40% of the Medicare -allowed amount Hospital ■ $0 copay per day, after day 7 after $2,000 out -of -network deductible Coverage 0 (Authorization applies to in - network services only.) Outpatient • $75 copay per visit for Medicare- • 40% of the Medicare -allowed amount Hospital covered observation services after $2,000 out -of -network deductible Coverage . $250 copay for all other services 0 Ambulatory • $200 copay for surgery services • 40% of the Medicare -allowed amount Surgical Center provided at an Ambulatory after $2,000 out -of -network deductible (ASC) Services Surgical Center 0 Doctor Visits ■ $25 copay per provider of choice • 40% of the Medicare -allowed amount visit after $2,000 out -of -network deductible ■ $45 copay per specialist visit Preventive • $0 copay ■ 40% of the Medicare -allowed amount Care ■ Abdominal aortic aneurysm screening ■ Annual wellness visit • Bone mass measurement • Breast cancer screening 4 330