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Florida Blue In the pursuit of health Indian River County Board of County Commissioners 2014 BlueMedicare Group PPO* Health Benefits '`':...,t +`St 1� � " .. hi 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. ,g ' 'Rie..,+«` :in �;i': y e . fe4_N.✓�, �. ....{t` �'€.�"� �' , t� ►F � (l. ��:: F-ik . �. �: 4 �'+ F f :��, .. �4, ..� 'r • �'., 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 $5 copay Out -of -Network CYD & 20% ''- `` r"4A •n .. rj. x'r^" �.i$ �w .. "'t'�" ��ww , e t_ - '.w.t +a,� #� y :� �!. : _.. (i4, • f u. s3 A'i"S7n4}.kafF Ss`4YY�"aw^`P.aY' o a� 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% Outpatient Surgery Y0011_31917 0913R2 EGWP C: 09/2013 1 101