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Flor • Etta In the pursuit of health' 13y�8 �} t % q ib t �. me# �te iK 5 � ,.. 'x F �(uei�eda,rp �rac�p��7 Home Health In -Network / Out -of -Network $0 copay Ambulance In -Network / Out -of -Network $150 copay for Medicare -covered ambulance services Qutpatient lledIcaervices `arwdl SuppUea Durable Medical Equipment/Diabetic Supplies • Diabetic Supplies (glucose meters, test strips and Lancets) — needles, syringes and insulin for self -injection is covered under your Part D benefit • Equipment: Electric customized wheelchairs, electric scooters • All other Medicare -covered durable medical equipment In -Network $0 copay Out -of -Network CYD & 20% In -Network 20% coinsurance Out -of -Network CYD & 20% In -Network $0 copay Out -of -Network CYD & 20% Prosthetic Devices In -Network $0 copay for Medicare -covered items Out -of -Network CYD & 20% Outpatient Rehabilitation - Office or Free Standing Facility Services: • Occupational Therapy • Physical Therapy • Speech and Language Therapy • Cardiac and Pulmonary Rehab • Dialysis In -Network $30 copay for each visit Out -of -Network CYD & 20% In-Network/Out-of-Network 20% coinsurance Outpatient Rehabilitation — Outpatient Hospital Services: • Occupational Therapy • Physical Therapy • Speech and Language Therapy • Cardiac and Pulmonary Rehab In -Network $30 copay for each visit Out -of -Network CYD & 20% } Ir�pa#%nt (Care ,,.' Y Inpatient Hospital Care (includes Substance Abuse) In -Network • $150 copay each day for day(s) 1-7 for a Medicare -covered stay in a network hospital • After the 7th day, the plan pays 100% of covered expenses per stay. Out -of -Network CYD & 20% Inpatient Mental Health Care (may also include Substance Abuse) In -Network • $200 copay each day for day(s) 1-7 for a Medicare -covered stay in a network psychiatric hospital • For day(s) 8-90, $0 copay for Y0011_31917 0913R2 EGWP C: 09/2013 3