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:r Iii the PLA-suit o: health BlueWdicare GroupPPW-Plan.1 Inpatient Mental Health Care In-Network • $200 Copayment each day for day(s) 1-7 for a Medicare-covered stay in a network hospital • $0 Copayment for day(s) 8-90 for a Medicare-covered stay in a network hospital • 190-day lifetime limit in a psychiatric hospital Out-of-Network DED & 20% Coinsurance Skilled Nursing Facility In-Network (in a Medicare-certified skilled nursing . $0 Copayment each day for days 1-20 per facility) benefit period • $75 Copayment each day for days 21-100 per benefit period • There is a limit of 100 days for each benefit period • 3-day prior hospital stay is not required Out_of-Network DED & 20% Coinsurance i Hospice Member must receive care from a Medicare- i certified hospice r� j Ve'Am-. ..•2V_'1 _6,;•Y-:`p - t- �I flue SenrisesM1- N `` �`5 ��X t t 36-U> DR2. Annual Screening Mammograms In-Network $0 Copayment for Medicare-covered (for women with Medicare, age 40 and older) screening mammograms Out-of-Network 20% Coinsurance Pap Smears and Pelvic Exams In-Network (for women with Medicare) • $0 Copayment per Pap smear • $0 Copayment per pelvic exam Out-of-Network 20% Coinsurance Bone Mass Measurement In-Network $0 Copayment for each Medicare- I (for people with Medicare who are at risk) covered bone mass measurement Out-of-Network 20% Coinsurance i Colorectal Screening Exams In-Network $0 Copayment for Medicare-covered i (for people with Medicare age 50 and older) ! colorectal screening exams 1 Out-of-Network 20% Coinsurance Prostate Cancer Screening Exams In-Network $0 Copayment for Medicare-covered (for men with Medicare age 50 and older) prostate cancer screening exams Out-of-Network 20% Coinsurance Y0011_31874 0414R4 EGWP C: 06/2014 5 107