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In the pursuit of heath <br /> GroupBenefits BlueMedicare e <br /> Outpatient Hospital Services (per visit). <br /> Occupational Therapy, Physical Therapy, In-Network $30 Copayment <br /> Speech & Language Therapy, Cardiac-and Out-of-Network DED & 20% Coinsurance <br /> Pulmonary Rehab (including intensive <br /> cardiac rehab) <br /> Radiation Therapy In-Network $50 Copayment <br /> Out-of-Network DED & 20% Coinsurance <br /> Dialysis In-Network/Out-of-Network 20% Coinsurance <br /> Lab Only In-Network.$15 Copayment <br /> Out-of-Network DED & 20% Coinsurance <br /> All Other Diagnostic Tests, X-Rays, In-Network $150 Copayment <br /> Advanced Imaging, etc. Out-of-Network DED & 20% Coinsurance <br /> Urgently Needed Care In-Network/Out-of-Network $30 Copayment <br /> (This is not emergency care, and in most <br /> cases is out-of-the-service area.) <br /> Emergency Services In-Network/Out-of-Network $50 Copayment <br /> Worldwide Coverage <br /> Dental, Hearing and Vision (Medicare- _ In-Network $30 Copayment j <br /> Covered) —�—' Out-of-Network DED & 20% Coinsurance — <br /> Home Health In-Network/Out-of-Network $0 Copayment <br /> Ambulance In-Network/Out-of-Network $150 Copayment for <br /> Medicare-covered ambulance services <br /> Y0011_31874 0414R4 EGWP C: 06/2014 3 <br /> 105 � <br />