Monthly Premium, Deductible and Limits 
Monthly Plan Premium $0 
You must keep paying your Medicare Part Bpremium. 
Medical deductible This plan does not have adeductible.  
Pharmacy (Part D) deductible This plan does not have adeductible. 
Maximum out-of-pocket 
responsibility $3,900 in-network 
The most you pay for copays, coinsurance and other costs for covered 
medical services for the year. 
Covered Medical and Hospital Benefits  
Acute inpatient hospital care $250 copay per day for days 1-7