PLAN G (continued): G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed $240 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 PLAN G PAYS YOU PAY PAYS 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 $240 of Medicare approved $240 amounts* $0 $0 (Part B Deductible) Remainder of Medicare approved Generally 80% Generally 20% $0 amounts Part B Excess Charges $0 100% $0 (above Medicare approved amounts) BLOOD First 3 pints $0 3 pints $0 Next $240 of Medicare approved $240 amounts* $0 $0 (Part B Deductible) Remainder of Medicare approved 80% 20% $0 amounts CLINICAL LABORATORY SERVICES Tests for diagnostic services 100% $0 $0 MEDICARE (PARTS A & B) HOME HEALTH CARE - Medicare approved services Medically Necessary Skilled Care 100% $0 $0 Services and Medical Supplies Durable Medical Equipment First $240 of Medicare approved $0 $0 $240 amounts* (Part B Deductible) Remainder of Medicare approved 80% 20% $0 amounts 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 $0 $0 $250 80% to a lifetime 20% and amounts Remainder of charges $0 maximum benefit over the $50,000 of $50,000 lifetime maximum GOCW-G