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Monthly Premium, Deductible and Limits <br />Monthly Plan $337.99 <br />Premium <br />You must continue to pay your Medicare Part B premium. <br />Deductible ■ $0 per year for In -Network healthcare services <br />■ $2,000 per year for Out -of -Network health care services <br />■ $0 per year for Part D prescription drugs. There is no deductible for <br />insulins. <br />Maximum ■ $1,000 is the most you pay for copays, coinsurance, and other costs for <br />Out -of -Pocket Medicare -covered medical services from in -network providers for the <br />Responsibility year. <br />■ $3,000 is the most you pay for copays, coinsurance, and other costs for <br />Medicare -covered medical services you receive from in- and <br />out -of -network providers. <br />Medical and Hospital Benefits <br />In1,1%orl 0 <br />f=levi'►r ! <br />Inpatient ■ $200 copay per day, for days 1-7 40% of the Medicare -allowed <br />Hospital ■ $0 copay per day, after day 7 amount after $2,000 <br />Coverage 0 out -of -network deductible <br />(Authorization <br />applies to <br />in -network <br />services only.) <br />Outpatient ■ $75 copay per visit for <br />Hospital Medicare -covered observation <br />Coverage services <br />■ $250 copay for all other services 0 <br />■ $0 copay for diagnostic <br />colonoscopy <br />G! <br />■ 40% of the Medicare -allowed <br />amount after $2,000 <br />out -of -network deductible <br />