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Outpatient Hospital Services (per visit): <br />Occupational Therapy, Physical Therapy, <br />Speech & Language Therapy, Cardiac <br />Rehab (including intensive cardiac rehab) <br />Pulmonary Rehab <br />Radiation Therapy <br />Dialysis <br />Lab Only <br />All Other Diagnostic Tests, X -Rays, <br />Advanced Imaging, etc. <br />In -Network $40 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />$1,980 Physical and Speech Therapy Annual Benefit <br />Maximum. This limit is for 2017 and subject to <br />change by Medicare in 2018. <br />$1,980 Occupational Therapy Annual Benefit <br />Maximum. This limit is for 2017 and subject to <br />change by Medicare in 2018. <br />In -Network $30 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />In -Network $50 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />In -Network / Out -of -Network 20% Coinsurance <br />In -Network $30 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />In -Network $250 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />Urgently Needed Care In -Network / Out -of -Network $50 Copayment <br />(This is not emergency care, and in most <br />cases is out -of -the -service area.) <br />Emergency Services (Including Worldwide <br />Coverage) <br />Dental, Hearing and Vision (Medicare - <br />Covered) <br />In -Network / Out -of -Network $75 Copayment <br />In -Network $50 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />Home Health In -Network / Out -of -Network $0 Copayment <br />Ambulance In -Network / Out -of -Network $150 Copayment for <br />Medicare -covered ambulance services <br />Y0011 33939 0817 EGWP C: 09/2017 3 <br />