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/ <br /> / <br /> F-4 <br /> In the OU[SUi+ of health <br /> -Benefits BlueMedicare Group PPO' Plan 1 <br /> IRS <br /> N*1 ,MR,`F <br /> Outpatient Surgery In-Network <br /> * $150 Copayment for each outpatient <br /> hospital facility visit <br />' <br /> * $100 Copayment for each visit to an <br /> ambulatory surgical center <br /> Out-of-Network DED & 20% Coinsurance <br /> In-Network/Out-of-Network <br /> 0 $0 Copayment for physician services <br /> Diagnostic Tests, X-Rays <br /> Office In-Network <br /> • Specialist $30 Copayment <br /> Out-of-Network DED & 20% Coinsurance <br /> IDTF In-Network $50 Copayment <br /> Out-of-Network DED & 20% Coinsurance <br /> Lab Services <br /> Independent Clinical Lab In-Network $0 Copayment <br /> Outpatient Hospital In-Network $15 Copayment <br /> All Locations Out-of-Network DED & 20% Coinsurance <br /> Advanced Imaging (MRI, MRA, CT Scan, <br /> PET Scan and Nuclear Medicine): <br /> Office In-Network $125 Copayment <br /> Out-of-Network DED & 20% Coinsurance <br /> IDTF In-Network $125 Copayment <br /> Out-of-Network DED & 20% Coinsurance <br /> Outpatient Hospital In-Network $150 Copayment <br /> Out-of-Network DED & 20% Coinsurance <br /> �� ���-------- --� ----� | <br /> | <br /> . . <br /> Y0011 31874O414R4EG\�UzC� U8/2O14 <br /> - 2 <br /> 104 <br />