2022 - 6 - Summary of Benefits H1036265001 
Monthly Premium, Deductible and Limits 
Monthly Plan Premium $0 
You must keep paying your Medicare Part Bpremium. 
Part Bpremium reduction Your plan will reduce your Monthly Part Bpremium by up to  $145 
Medical deductible This plan does not have adeductible.  
Pharmacy (Part D) deductible This plan does not have adeductible. 
Maximum out-of-pocket 
responsibility $2,750 in-network 
The most you pay for copays, coinsurance and other costs for medical