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i <br /> In the pursuit of health` <br /> '.Benefits�k � r -._�::�.x:��..��r; - :.,�� _•.,.�.: �q_�-•, .,.,_.��v., <br /> r �- ;z.:i �BlueMe'clicarerG�ou�•f PPO*Pt'an1�•�,:� ��•:< <br /> 'a. :a� .i;. ,s..z& S _ _ .-ri`-`.'' �2`.• N rte. M_r.,? :at:-_� .4�. i �,1=�^' <br /> Home Health In-Network/Out-of-Network $0 copay <br /> Ambulance In-Network/Out-of-Network $150 copay for <br /> Medicare-covered ambulance services <br /> *' '< - ',s*s. ,'•rs'* r� ..- •�. - '`L3{=xr.':E:.: '-'F...jr.:-�- .ri:= - i <br /> Qutpatien;NO r I d`Su <br /> d ca Serv�ces`�'an _Pp. ,�° .�= ..,:�`�,.>x=�'• ,�:;'_. .�"�- <br /> Durable Medical Equipment/Diabetic Supplies <br /> • Diabetic Supplies (glucose meters, test In-Network $0 copay <br /> strips and Lancets)—needles, syringes Out-of-Network CYD & 20% <br /> and insulin for self-injection is covered <br /> under your Part D benefit <br /> • Equipment: Electric customized In-Network 20% coinsurance <br /> wheelchairs, electric scooters Out-of-Network CYD & 20% <br /> • All other Medicare-covered durable In-Network $0 copay <br /> medical equipment Out-of-Network CYD & 20% <br /> Prosthetic Devices In-Network $0 copay for Medicare-covered <br /> items <br /> Out-of-Network CYD & 20% <br /> Outpatient Rehabilitation - Office or Free <br /> Standing Facility Services: <br /> • Occupational Therapy In-Network $30 copay for each visit <br /> • Physical Therapy Out-of-Network CYD & 20% <br /> • Speech and Language Therapy <br /> • Cardiac and Pulmonary Rehab <br /> • Dialysis In-Network/Out-of-Network 20% coinsurance <br /> Outpatient Rehabilitation —Outpatient Hospital <br /> Services: <br /> • Occupational Therapy In-Network $30 copay for each visit <br /> • Physical Therapy Out-of-Network CYD & 20% <br /> • Speech and Language Therapy <br /> • Cardiac and Pulmonary Rehab <br /> ,".,.-.c-i: <br /> :� 'Care <br /> p }�. <br /> In a#ienf <br /> ti-e�L`•��: - t' ..-.*i'�. .�"G•%}rvi :}u't�\i. _ .'^c.-£•,;:' t,� �r 1•-.,C.I- ..h. . a':!'�6.d'=i'M�e.'t <br /> Inpatient Hospital Care In-Network <br /> (includes Substance Abuse) . $150 copay each day for day(s) 1-7 <br /> for a Medicare-covered stay in a <br /> network hospital <br /> • After the 7'h day, the plan pays 100% <br /> of covered expenses per stay <br /> Out-of-Network CYD & 20% <br /> Inpatient Mental Health Care In-Network <br /> (may also include Substance Abuse) • $200 copay each day for day(s) 1-7 <br /> for a Medicare-covered stay in a <br /> network psychiatric hospital <br /> • For day(s) 8-90, $0 copay for <br /> Y0011_31917 0913R2 EGWP C. 09/2013 3 <br /> i <br />