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Z%Wfell 09 <br /> In the pursuit cf health <br /> Benefits, <br /> BlueMedicare:Gro. up PPO*�Plan I <br /> IN <br /> St fi" ali <br /> Me <br /> Durable Medical Equipment/Diabetic <br /> Supplies <br /> Diabetic Supplies (glucose meters, test strips In-Network $0 Copayment <br /> and lancets) Out-of-Network DED & 20% Coinsurance <br /> Note: needles, syringes and insulin for self- <br /> injection are covered under your Part D <br /> benefit <br /> Equipment: Plan-Approved Electric In-Network 20% Coinsurance <br /> Customized Wheelchairs, Electric Scooters Out-of-Network DED & 20% Coinsurance <br /> All Other Medicare-Covered Durable Medical In-Network $0 Copayment <br /> Equipment Out-of-Network DED & 20% Coinsurance <br /> Prosthetic Devices In-Network $0 Copayment for Medicare-covered <br /> items <br /> Out-of-Network DED & 20% Coinsurance <br /> Outpatient Rehabilitation <br /> Occupational Therapy, Physical Therapy, <br /> Speech & Language Therapy, Cardiac and <br /> Pulmonary Rehab (including intensive <br /> cardiac rehab) <br /> Office or Freestanding Facility In-Network $30 Copayment for each visit <br /> Services Out-of-Network DED & 20% Coinsurance <br /> Outpatient Hospital Services In-Network $30 Copayment for each visit <br /> Out-of-Network DED & 20% Coinsurance <br /> Dialysis In-Network/Out-of-Network 20% Coinsurance <br /> gtx <br /> Up <br /> 'Ns <br /> V. <br /> Inpatient Hospital Care In-Network <br /> (including substance abuse treatment) 0 $150 Copayment each day for day(s) 1-7 <br /> for a Medicare-covered stay in a network <br /> hospital <br /> 0 After the 7th day, the plan pays 100% of <br /> covered expenses per stay <br /> Out-of-Network DED & 20% Coinsurance <br /> J <br /> Y0011_31874 0414R4 EGWP C. 06/2014 4 <br /> 106 <br />