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Flarida Z3kee 0d <br />In the pursuit of health <br />Indian River County BOCC #90000 <br />2018 BlueMedicare Group PPO (Employer PPO) Health Benefits <br />Premium (per member, per month) <br />Annual Deductible <br />Out -of Pocket Maximum (based on plan <br />year) <br />ysician Office <br />$316.55 for PP02Rx1 <br />$0 In -Network / $2,000 Out -of -Network <br />$2,000 In -Network / $4,000 Out -of -Network <br />In -Network out-of-pocket maximum accumulates <br />toward Out -of -Network out-of-pocket maximum <br />Primary Care (per visit) <br />In -Network $35 Copayment <br />Deductible & 40% Coinsurance <br />Specialist Care (per visit) <br />jOut-of-Network <br />I In -Network $50 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />Convenient Care Center <br />In -Network / Out -of -Network $50 Copayment <br />Podiatry Services (per visit) <br />In -Network $50 Copayment <br />(routine foot care up to 6 visits per year) <br />Out -of -Network Deductible & 40% Coinsurance <br />Chiropractic Services (per visit) In -Network $20 Copayment <br />For each Medicare -covered visit (manual Out -of -Network Deductible & 40% Coinsurance <br />manipulation of the spine to correct <br />subluxation) <br />Outpatient Mental Health Care (per visit) <br />For individual or group therapy <br />(including partial hospitalization) <br />Outpatient Substance Abuse Care (per visit) <br />I Part B drugs (including chemotherapy) <br />Allergy Injections <br />In -Network $40 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />In -Network $40 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />In -Network 20% coinsurance <br />Out -of -Network Deductible & 40% Coinsurance <br />In -Network $10 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />Y0011 33939 0817 EGWP C: 09/2017 1 <br />