Common use of Summary of Benefits Clause in Contracts

Summary of Benefits. Medicare Part A helps pay for health care in hospitals, skilled nursing facilities, hospice care, and some home health care services. The table below shows how much Medicare, this plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan Select G. Medicare Part A: Hospital Services per Benefit Period Service Limits Medicare Pays Plan Pays You Pay Hospitalization (*) Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,556 $1,556 (Part A deductible) $0 Days 61 thru 90 All but $389 per day $389 per day $0 Days 91 and after while using 60 lifetime reserve days All but $778 per day $778 per day $0 Once lifetime reserve days are used, an additional 365 days $0 100% of Medicare eligible expenses (**) $0(**) Beyond the additional 365 days $0 $0 100% Skilled Nursing Facility (SNF) Care (*) You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 Days 21 thru 100 All but $194.50 per day Up to $194.50 per day $0 Days 101 and after $0 $0 100% Blood (inpatient) First 3 pints $0 100% $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment or coinsurance for outpatient drugs and inpatient respite care Medicare copayment or coinsurance for outpatient drugs and inpatient respite care $0 (*) A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. (**) When your Medicare Part A hospital benefits are exhausted, BCBSRI stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. Medicare Part B helps pay for doctors’ services, outpatient hospital care, certain medically necessary home health care services and other medical services that Part A does not cover, such as physical and speech therapy. The table below shows how much Medicare, your plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan G. Medicare Part B: Medical Services per Calendar Year Service Limits Medicare Pays Plan Pays You Pay Medical Expenses Includes treatment in or out of the hospital and outpatient hospital treatment, such as: doctor’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment First $233 of Medicare-approved amounts(^) $0 $0 $233 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 100% $0 Blood First 3 pints $0 100% $0 Next $233 of Medicare-approved amounts(^) $0 $0 $233 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 Clinical Laboratory Services Tests for diagnostic services 100% $0 $0 Medicare Parts A and B Service Limits Medicare Pays Plan Pays You Pay Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipment Medicare-approved services First $233 of Medicare-approved amounts(^) $0 $0 $233 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 ^ Once you have been billed $233 of Medicare-approved amounts for covered services (which are noted with a carrot), your Part B deductible will have been met for the calendar year. Other Benefits – Not Covered by Medicare Service Medicare Pays Plan Pays You Pay 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 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum Note: The Summary of Benefits contains only a brief summary of Medicare benefits. Please contact your local Social Security Office or consult the “Medicare & You” handbook for details about Medicare.

Summary of Benefits. Medicare Part A helps pay for health care in hospitals, skilled nursing facilities, hospice care, and some home health care services. The table below shows how much Medicare, this plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan Select G. Medicare Part A: Hospital Services per Benefit Period Service Limits Medicare Pays Plan Pays You Pay Hospitalization (*) Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,556 1,600 $1,556 1,600 (Part A deductible) $0 Days 61 thru 90 All but $389 400 per day $389 400 per day $0 Days 91 and after while using 60 lifetime reserve days All but $778 800 per day $778 800 per day $0 Once lifetime reserve days are used, an additional 365 days $0 100% of Medicare eligible expenses (**) $0(**) Beyond the additional 365 days $0 $0 100% Skilled Nursing Facility (SNF) Care (*) You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 Days 21 thru 100 All but $194.50 200 per day Up to $194.50 200 per day $0 Days 101 and after $0 $0 100% Blood (inpatient) First 3 pints $0 100% $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment or coinsurance for outpatient drugs and inpatient respite care Medicare copayment or coinsurance for outpatient drugs and inpatient respite care $0 (*) A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. (**) When your Medicare Part A hospital benefits are exhausted, BCBSRI stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. Medicare Part B helps pay for doctors’ services, outpatient hospital care, certain medically necessary home health care services and other medical services that Part A does not cover, such as physical and speech therapy. The table below shows how much Medicare, your plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan G. Medicare Part B: Medical Services per Calendar Year Service Limits Medicare Pays Plan Pays You Pay Medical Expenses Includes treatment in or out of the hospital and outpatient hospital treatment, such as: doctor’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment First $233 226 of Medicare-approved amounts(^) $0 $0 $233 226 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 100% $0 Blood First 3 pints $0 100% $0 Next $233 226 of Medicare-approved amounts(^) $0 $0 $233 226 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 Clinical Laboratory Services Tests for diagnostic services 100% $0 $0 Medicare Parts A and B Service Limits Medicare Pays Plan Pays You Pay Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipment Medicare-approved services First $233 226 of Medicare-approved amounts(^) $0 $0 $233 226 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 ^ Once you have been billed $233 226 of Medicare-approved amounts for covered services (which are noted with a carrot), your Part B deductible will have been met for the calendar year. Other Benefits – Not Covered by Medicare Service Medicare Pays Plan Pays You Pay 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 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum Note: The Summary of Benefits contains only a brief summary of Medicare benefits. Please contact your local Social Security Office or consult the “Medicare & You” handbook for details about Medicare.

Summary of Benefits. Medicare Part A helps pay for health care in hospitals, skilled nursing facilities, hospice care, and some home health care services. The table below shows how much Medicare, this plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan Select G. Medicare Part A: Hospital Services per Benefit Period Service Limits Medicare Pays Plan Pays You Pay Hospitalization (*) Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,556 1,408 $1,556 1,408 (Part A deductible) $0 Days 61 thru 90 All but $389 352 per day $389 352 per day $0 Days 91 and after while using 60 lifetime reserve days All but $778 704 per day $778 704 per day $0 Once lifetime reserve days are used, an additional 365 days $0 100% of Medicare eligible expenses (**) $0(**) Beyond the additional 365 days $0 $0 100% Skilled Nursing Facility (SNF) Care (*) You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 Days 21 thru 100 All but $194.50 176 per day Up to $194.50 176 per day $0 Days 101 and after $0 $0 100% Blood (inpatient) First 3 pints $0 100% $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment or coinsurance for outpatient drugs and inpatient respite care Medicare copayment or coinsurance for outpatient drugs and inpatient respite care $0 (*) A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. (**) When your Medicare Part A hospital benefits are exhausted, BCBSRI stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. Medicare Part B helps pay for doctors’ services, outpatient hospital care, certain medically necessary home health care services and other medical services that Part A does not cover, such as physical and speech therapy. The table below shows how much Medicare, your plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan G. Medicare Part B: Medical Services per Calendar Year Service Limits Medicare Pays Plan Pays You Pay Medical Expenses Includes treatment in or out of the hospital and outpatient hospital treatment, such as: doctor’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment First $233 198 of Medicare-approved amounts(^) $0 $0 $233 198 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 100% $0 Blood First 3 pints $0 100% $0 Next $233 198 of Medicare-approved amounts(^) $0 $0 $233 198 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 Clinical Laboratory Services Tests for diagnostic services 100% $0 $0 Medicare Parts A and B Service Limits Medicare Pays Plan Pays You Pay Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipment Medicare-approved services First $233 198 of Medicare-approved amounts(^) $0 $0 $233 198 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 ^ Once you have been billed $233 198 of Medicare-approved amounts for covered services (which are noted with a carrot), your Part B deductible will have been met for the calendar year. Other Benefits – Not Covered by Medicare Service Medicare Pays Plan Pays You Pay 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 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum Note: The Summary of Benefits contains only a brief summary of Medicare benefits. Please contact your local Social Security Office or consult the “Medicare & You” handbook for details about Medicare.

Summary of Benefits. Medicare Part A helps pay for health care in hospitals, skilled nursing facilities, hospice care, and some home health care services. The table below shows how much Medicare, this plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan Select G. F. Medicare Part A: Hospital Services per Benefit Period Service Limits Medicare Pays Plan Pays You Pay Hospitalization (*) Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,556 $1,556 (Part A deductible) $0 Days 61 thru 90 All but $389 per day $389 per day $0 Days 91 and after while using 60 lifetime reserve days All but $778 per day $778 per day $0 Once lifetime reserve days are used, an additional 365 days $0 100% of Medicare eligible expenses (**) $0(**) Beyond the additional 365 days $0 $0 100% Skilled Nursing Facility (SNF) Care (*) You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 Days 21 thru 100 All but $194.50 per day Up to $194.50 per day $0 Days 101 and after $0 $0 100% Blood (inpatient) First 3 pints $0 100% $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment or coinsurance for outpatient drugs and inpatient respite care Medicare copayment or coinsurance for outpatient drugs and inpatient respite care $0 (*) A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. (**) When your Medicare Part A hospital benefits are exhausted, BCBSRI stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. Medicare Part B helps pay for doctors’ services, outpatient hospital care, certain medically necessary home health care services and other medical services that Part A does not cover, such as physical and speech therapy. The table below shows how much Medicare, your plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan G. Select F. Medicare Part B: Medical Services per Calendar Year Service Limits Medicare Pays Plan Pays You Pay Medical Expenses Includes treatment in or out of the hospital and outpatient hospital treatment, such as: doctor’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment First $233 of Medicare-approved amounts(^) $0 $0 $233 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 100% $0 Blood First 3 pints $0 100% $0 Next $233 of Medicare-approved amounts(^) $0 $0 $233 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 Clinical Laboratory Services Tests for diagnostic services 100% $0 $0 Medicare Parts A and B Service Limits Medicare Pays Plan Pays You Pay Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipment Medicare-approved services First $233 of Medicare-approved amounts(^) $0 $0 $233 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 ^ Once you have been billed $233 of Medicare-approved amounts for covered services (which are noted with a carrot), your Part B deductible will have been met for the calendar year. Other Benefits – Not Covered by Medicare Service Medicare Pays Plan Pays You Pay 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 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum Note: The Summary of Benefits contains only a brief summary of Medicare benefits. Please contact your local Social Security Office or consult the “Medicare & You” handbook for details about Medicare.

Summary of Benefits. Medicare Part A helps pay for health care in hospitals, skilled nursing facilities, hospice care, and some home health care services. The table below shows how much Medicare, this plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan Select G. F. Medicare Part A: Hospital Services per Benefit Period Service Limits Medicare Pays Plan Pays You Pay Hospitalization (*) Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,556 1,600 $1,556 1,600 (Part A deductible) $0 Days 61 thru 90 All but $389 400 per day $389 400 per day $0 Days 91 and after while using 60 lifetime reserve days All but $778 800 per day $778 800 per day $0 Once lifetime reserve days are used, an additional 365 days $0 100% of Medicare eligible expenses (**) $0(**) Beyond the additional 365 days $0 $0 100% Skilled Nursing Facility (SNF) Care (*) You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 Days 21 thru 100 All but $194.50 200 per day Up to $194.50 200 per day $0 Days 101 and after $0 $0 100% Blood (inpatient) First 3 pints $0 100% $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment or coinsurance for outpatient drugs and inpatient respite care Medicare copayment or coinsurance for outpatient drugs and inpatient respite care $0 (*) A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. (**) When your Medicare Part A hospital benefits are exhausted, BCBSRI stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. Medicare Part B helps pay for doctors’ services, outpatient hospital care, certain medically necessary home health care services and other medical services that Part A does not cover, such as physical and speech therapy. The table below shows how much Medicare, your plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan G. Select F. Medicare Part B: Medical Services per Calendar Year Service Limits Medicare Pays Plan Pays You Pay Medical Expenses Includes treatment in or out of the hospital and outpatient hospital treatment, such as: doctor’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment First $233 226 of Medicare-approved amounts(^) $0 $0 $233 226 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 100% $0 Blood First 3 pints $0 100% $0 Next $233 226 of Medicare-approved amounts(^) $0 $0 $233 226 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 Clinical Laboratory Services Tests for diagnostic services 100% $0 $0 Medicare Parts A and B Service Limits Medicare Pays Plan Pays You Pay Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipment Medicare-approved services First $233 226 of Medicare-approved amounts(^) $0 $0 $233 226 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 ^ Once you have been billed $233 226 of Medicare-approved amounts for covered services (which are noted with a carrot), your Part B deductible will have been met for the calendar year. Other Benefits – Not Covered by Medicare Service Medicare Pays Plan Pays You Pay 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 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum Note: The Summary of Benefits contains only a brief summary of Medicare benefits. Please contact your local Social Security Office or consult the “Medicare & You” handbook for details about Medicare.

Summary of Benefits. Medicare Part A helps pay for health care in hospitals, skilled nursing facilities, hospice care, and some home health care services. The table below shows how much Medicare, this plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan Select G. F. Medicare Part A: Hospital Services per Benefit Period Service Limits Medicare Pays Plan Pays You Pay Hospitalization (*) Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,556 1,484 $1,556 1,484 (Part A deductible) $0 Days 61 thru 90 All but $389 371 per day $389 371 per day $0 Days 91 and after while using 60 lifetime reserve days All but $778 742 per day $778 742 per day $0 Once lifetime reserve days are used, an additional 365 days $0 100% of Medicare eligible expenses (**) $0(**) Beyond the additional 365 days $0 $0 100% Skilled Nursing Facility (SNF) Care (*) You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 Days 21 thru 100 All but $194.50 185.50 per day Up to $194.50 185.50 per day $0 Days 101 and after $0 $0 100% Blood (inpatient) First 3 pints $0 100% $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment or coinsurance for outpatient drugs and inpatient respite care Medicare copayment or coinsurance for outpatient drugs and inpatient respite care $0 (*) A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. (**) When your Medicare Part A hospital benefits are exhausted, BCBSRI stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. Medicare Part B helps pay for doctors’ services, outpatient hospital care, certain medically necessary home health care services and other medical services that Part A does not cover, such as physical and speech therapy. The table below shows how much Medicare, your plan, and you pay for specific services. Please note, you pay for any services not covered by Medicare A & B or Plan 65 Medicare Supplement Plan G. Select F. Medicare Part B: Medical Services per Calendar Year Service Limits Medicare Pays Plan Pays You Pay Medical Expenses Includes treatment in or out of the hospital and outpatient hospital treatment, such as: doctor’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment First $233 203 of Medicare-approved amounts(^) $0 $0 $233 203 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (Above Medicare-approved amounts) $0 100% $0 Blood First 3 pints $0 100% $0 Next $233 203 of Medicare-approved amounts(^) $0 $0 $233 203 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 Clinical Laboratory Services Tests for diagnostic services 100% $0 $0 Medicare Parts A and B Service Limits Medicare Pays Plan Pays You Pay Home Health Care Medicare-approved services Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipment Medicare-approved services First $233 203 of Medicare-approved amounts(^) $0 $0 $233 203 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 ^ Once you have been billed $233 203 of Medicare-approved amounts for covered services (which are noted with a carrot), your Part B deductible will have been met for the calendar year. Other Benefits – Not Covered by Medicare Service Medicare Pays Plan Pays You Pay 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 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum Note: The Summary of Benefits contains only a brief summary of Medicare benefits. Please contact your local Social Security Office or consult the “Medicare & You” handbook for details about Medicare.