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rye. V. <br /> In the pursuit of health' <br /> f .,mo- -i:i;it,;'N•}.;f �,yt�'M•., ;h,y ?x..: - •'�' - '4-`Y' tbi- t!.'.s}.:-mss,. i7.,'•:/.�c..:=�;!* <br /> .Benefifs:=��:� - :,: r.; ;-,�a. ��•-- - �;BlueMedica�e�G�ou`�P'PO -Ptan=1:�3�= ��� �•. <br /> In-Network/Out-of-Network <br /> • $0 copay for Physician Services <br /> Diagnostic Tests, X-Rays <br /> Office In-Network <br /> • PCP $10 copay <br /> • Specialist $30 copay <br /> Office visit copay may apply <br /> Out-of-Network CYD & 20% <br /> IDTF In-Network $50 copay <br /> Out-of-Network CYD & 20% <br /> Lab Services <br /> Independent Clinical Lab In-Network $0 copay <br /> Outpatient Hospital In-Network $15 copay <br /> Office visit or facility copay may apply <br /> Out-of-Network CYD & 20% <br /> Advanced Imaging (MRI, MRA, Cat Scan, Pet <br /> Scan & Nuclear Med)- In-Network $125 copay <br /> Office Out-of-Network CYD & 20% <br /> IDTF In-Network $125 copay <br /> Out-of-Network CYD & 20% <br /> Outpatient Hospital In-Network $150 copay <br /> Out-of-Network CYD & 20% <br /> Outpatient Hospital Services (per visit): <br /> In-Network Out-of-Network <br /> • Occupational Therapy, Physical $30 CYD & 20% <br /> Therapy, Speech & Language Therapy, <br /> Cardiac and Pulmonary Rehab <br /> • Radiation $50 CYD & 20% <br /> • Dialysis 20% 20% <br /> • Lab only $15 CYD & 20% <br /> • All other Diagnostic Tests, X-Rays $150 CYD & 20% <br /> Advanced Imaging, etc. <br /> Urgently Needed Care In-Network/Out-of-Network $30 copay <br /> (This is not emergency care, and in most cases <br /> is out of the service area.) <br /> Emergency Services In-Network/Out-of-Network $50 copay <br /> Worldwide coverage <br /> Dental - Medicare approved (No Preventive) In-Network $30 copay <br /> Out-of-Network CYD & 20% <br /> Y0011 31917 0913R2 EGWP C: 09/2013 2 <br /> I <br />