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FCrrrrda, 13eue �. d <br />In the pursuit of health <br />�,..xa .. .,'.,d.,.. <br />....i f <br />In-Network / Out -of -Network <br />• $0 copay for Physician Services <br />Diagnostic Tests, X -Rays <br />Office <br />IDTF <br />Lab Services <br />Independent Clinical Lab <br />Outpatient Hospital <br />Advanced Imaging (MRI, MRA, Cat Scan, Pet <br />Scan & Nuclear Med): <br />Office <br />IDTF <br />Outpatient Hospital <br />In -Network <br />• PCP $10 copay <br />• Specialist $30 copay <br />Office visit copay may apply <br />Out -of -Network CYD & 20% <br />In -Network $50 copay <br />Out -of -Network CYD & 20% <br />In -Network $0 copay <br />In -Network $15 copay <br />Office visit or facility copay may apply <br />Out -of -Network CYD & 20% <br />In -Network $125 copay <br />Out -of -Network CYD & 20% <br />In -Network $125 copay <br />Out -of -Network CYD & 20% <br />In -Network $150 copay <br />Out -of -Network CYD & 20% <br />Outpatient Hospital Services (per visit): <br />• Occupational Therapy, Physical <br />Therapy, Speech & Language Therapy, <br />Cardiac and Pulmonary Rehab <br />• Radiation <br />• Dialysis <br />• Lab only <br />• All other Diagnostic Tests, X -Rays <br />Advanced Imaging, etc. <br />In -Network Out -of -Network <br />$30 CYD & 20% <br />$50 CYD & 20% <br />20% 20% <br />$15 CYD & 20% <br />$150 CYD & 20% <br />Urgently Needed Care <br />(This is not emergency care, and in most cases <br />is out of the service area.) <br />In -Network / Out -of -Network $30 copay <br />Emergency Services <br />In -Network / Out -of -Network $50 copay <br />Worldwide coverage <br />Dental - Medicare approved (No Preventive) <br />In -Network $30 copay <br />Out -of -Network CYD & 20% <br />Y0011_31917 0913R2 EGWP C: 09/2013 <br />2 <br />102 <br />