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v o <br /> In the pursuit of health' <br /> Indian River County Board of County Commissioners <br /> 2014 BlueMedicare Group PPO* Health Benefits <br /> Ica <br /> _e 1 <br /> Premium (per member, per month) 4 $379.99 <br /> Deductible $0 In-Network $1,000 Out-of-Network <br /> Out-of Pocket Max $1,000 In-Network/$3,000 Out-of-Network. <br /> In-Network out-of-pocket max accumulates <br /> toward Out-of-Network out-of-pocket max. <br /> -- K <br /> Primary Care(per visit) In-Network $10 copay <br /> Out-of-Network CYD & 20% <br /> Specialist Care (per visit) In-Network $30 copay <br /> Out-of-Network CYD & 20% <br /> e-visit In-Network $5 copay <br /> Out-of-Network CYD & 20% <br /> Convenient Care Center In-Network $30 copay <br /> Out-of-Network CYD & 20% <br /> Podiatry Services (per visit) In-Network $30 copay <br /> (Routine foot care up to 6 visits per year) Out-of-Network CYD & 20% <br /> Chiropractic Services (per visit) In-Network $20 copay <br /> For each Medicare covered visit (manual Out-of-Network CYD & 20% <br /> manipulation of the spine to correct <br /> subluxation) <br /> Outpatient Mental Health Care (per visit) In-Network $35 copay <br /> For individual or group therapy Out-of-Network CYD & 20% <br /> Outpatient Substance Abuse Care (per visit) In-Network $35 copay <br /> Out-of-Network CYD & 20% <br /> Part B drugs (including Chemotherapy) In-Network 20% coinsurance <br /> Office visit or facility copay may apply <br /> Out-of-Network CYD & 20% coinsurance <br /> Office visit or facility charges may apply <br /> Allergy Injections In-Network $5 copay <br /> Out-of-Network CYD & 20% <br /> -TY, <br /> RP <br /> Outpatient Surgery In-Network <br /> 0 $150 copay for each outpatient <br /> hospital facility visit <br /> 0 $100 copay for each visit to an <br /> ambulatory surgical center <br /> Out-of-Network CYD & 20% <br /> Y0011_31917 0913R2 EGWP C 09/2013 1 <br />