Laserfiche WebLink
C✓' ' IrO g <br /> in the pursuit of health <br /> Indian River County BOCC #90000 <br /> 2015 BlueMedicare Group PPO* (Employer PPO) Health Benefits <br /> Benefits 1: BlueMedicare Group PP01 <br /> Premium (per member, per month) $319.92 for PPO1 Rx1 <br /> Annual Deductible (DED) :::j $0 In-Network/$1,000 Out-of-Network <br /> Out-of Pocket Maximum (based on plan $1,000 In-Network/$3,000 Out-of-Network <br /> year) In-Network out-of-pocket maximum accumulates <br /> toward Out-of-Network out-of-pocket maximum <br /> _ `yr�' �'. '• 9 i � •,��.i = o•-:: mo=w -ax- _ ,y_ <br /> Physlcfan O(flce -. R.{ <br /> Primary Care (per visit) In-Network $10 Copayment <br /> Out-of-Network DED & 20% Coinsurance <br /> Specialist Care (per visit) In-Network $30 Copayment <br /> Out-of-Network DED & 20% Coinsurance <br /> e-Visit In-Network $5 Copayment <br /> Out-of-Network DED & 20% Coinsurance <br /> Convenient Care Center In-Network/Out-of-Network $30 Copayment <br /> iPodiatry Services (per visit) In-Network $30 Copayment <br /> (routine foot care up to 6 visits per year) —_ _Out-of-Network DED & 20% Coinsurance <br /> Chiropractic Services (per visit) In-Network $20 Copayment <br /> For each Medicare-covered visit (manual Out-of-Network DED & 20% Coinsurance <br /> manipulation of the spine to correct <br /> subluxation) <br /> Outpatient Mental Health Care (per visit) In-Network $35 Copayment <br /> For individual or group therapy Out-of-Network DED & 20% Coinsurance <br /> (including partial hospitalization) <br /> Outpatient Substance Abuse Care (per visit) ! In-Network $35 Copayment —j <br /> Out-of-Network DED & 20% Coinsurance <br /> IPart B Drugs (including chemotherapy In-Network 20% Coinsurance <br /> Out-of-Network DED & 20% Coinsurance <br /> i-.-Allergy Injections In-Network $5 Copayment I <br /> Out-of-Network DED & 20% Coinsurance <br /> Y0011_31874 0414R4 EGWP C: 06/2014 1 <br /> 103 <br />