2015-025D - Laserfiche WebLink

Home Browse Search

In the pursuit of health' Indian River County Board of County Commissioners 2014 BlueMedicare Group PPO* Health Benefits Benefits � � R y ` BlueMedicare Group P0 P Premium (per member, per month) $379.99 Deductible $0 In -Network / $1,000 Out -of -Network Out -of Pocket Max $1,000 In -Network / $3,000 Out -of -Network. In -Network out-of-pocket max accumulates toward Out -of -Network out-of-pocket max. p .%i1$,C t�tlysi.iari OJfa.e,.} 4w.R*v'_1CiiY'1�,'..��1:*., Primary Care (per visit) In -Network $10 copay Out -of -Network CYD & 20% Specialist Care (per visit) In -Network $30 copay Out -of -Network CYD & 20% e -visit In -Network $5 copay Out -of -Network CYD & 20% Convenient Care Center In -Network $30 copay Out -of -Network CYD & 20% Podiatry Services (per visit) (Routine foot care up to 6 visits per year) In -Network $30 copay Out -of -Network CYD & 20% Chiropractic Services (per visit) For each Medicare covered visit (manual manipulation of the spine to correct subluxation) In -Network $20 copay Out -of -Network CYD & 20% Outpatient Mental Health Care (per visit) For individual or group therapy In -Network $35 copay Out -of -Network CYD & 20% Outpatient Substance Abuse Care (per visit) In -Network $35 copay Out -of -Network CYD & 20% Part B drugs (including Chemotherapy) In -Network 20% coinsurance Office visit or facility copay may apply Out -of -Network CYD & 20% coinsurance Office visit or facility charges may apply Allergy Injections In -Network $5 copay Out -of -Network CYD & 20% Other Services ' S t ` Outpatient Surgery In -Network • $150 copay for each outpatient hospital facility visit • $100 copay for each visit to an ambulatory surgical center Out -of -Network CYD & 20% Y0011_31917 0913R2 EGWP C: 09/2013 1