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FGonda, Blue �. 0 <br />In the pursuit of health" <br />}+t,` ,� rit� p`d <br />L°_^d Q _. r. <br />�+ro•.',�5'� " - <br />" . t <br />e e��� �,"�f""i:.: <br />Medicare -covered stay in a network <br />psychiatric hospital <br />190 -day lifetime limit in a psychiatric hospital <br />Out -of -Network CYD & 20% <br />Skilled Nursing Facility <br />(in a Medicare -certified skilled nursing facility) <br />In -Network <br />• $0 copay each day for days 1-20 per <br />benefit period <br />• $75 copay each day for days 21-100 <br />per benefit period <br />There is a limit of 100 days for each benefit <br />period <br />3 -day prior hospital stay is not required <br />Out -of -Network CYD & 20% <br />Hospice <br />Member must receive care from a Medicare - <br />certified hospice <br />t k, r tfi e xtyXl'a ..cg°4 su <br />r .. �; ]2 P:°. 4,. °."�. .. '.r� �, v . • a. r a <br />i':''iv <br />p� <br />t s+ r jx "'^e 's`` e.,?, .t.*x5a:;.s.{r M$ <br />, <br />.c, su i ,-;.. o a.. #:.., n ,.8 %3 il,%•4e 1.'+"i�ii' -i`S.+iP. Ml.e ,. Aw, . <br />Annual Screening Mammograms <br />(for women with Medicare age 40 and older) <br />In -Network: <br />• $0 copay for Medicare -covered <br />Screening Mammogram <br />Out -of -Network CYD & 20% <br />Pap Smears and Pelvic Exams <br />(for women with Medicare) <br />In -Network: <br />• $0 copay per Pap smear <br />• $0 copay per pelvic exam <br />Out -of -Network CYD & 20% <br />Bone Mass Measurement <br />(for people with Medicare who are at risk) <br />In -Network: <br />• $0 copay for each Medicare -covered <br />Bone Mass Measurement <br />Out -of -Network CYD & 20% <br />Colorectal Screening Exams <br />(for people with Medicare age 50 and older) <br />In -Network: <br />• $0 copay for Medicare -covered <br />Colorectal screening exam <br />Out -of -Network CYD & 20% <br />Prostate Cancer Screening Exams <br />(for men with Medicare age 50 and older) <br />In -Network: <br />• $0 copay for Medicare -covered <br />Prostate Cancer Screening exam <br />Out -of -Network CYD & 20% <br />Vaccines — Medicare covered <br />.723,74,: fah, fi ." ?.a r ua '' h <br />H?ep?Q Srnefi ' <br />�E.R"-�'. 3, fi�m-,a,�;: <br />In -Network / Out -of -Network <br />• $0 copay for Influenza vaccine <br />• $0 copay for Pneumococcal vaccine <br />• $0 copay for Hepatitis B vaccine <br />Fitness <br />Free membership through SilverSneakers <br />Y0011_31917 0913R2 EGWP C: 09/2013 <br />4 <br />104 <br />