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Outpatient Medical Services and Supplies Durable Medical Equipment/Diabetic Supplies Diabetic Supplies (glucose meters, test strips and lancets) Note: needles, syringes and insulin for self - injection are covered under your Part D benefit Equipment: Plan -Approved Electric Customized Wheelchairs, Electric Scooters All Other Medicare -Covered Durable Medical Equipment Prosthetic Devices Outpatient Rehabilitation Occupational Therapy, Physical Therapy, Speech & Language Therapy, Cardiac Rehab (including intensive cardiac rehab) Office or Freestanding Facility Services Outpatient Hospital Services Pulmonary Rehab Dialysis ent Care Inpatient Hospital Care (including substance abuse treatment) In -Network $0 Copayment Out -of -Network Deductible & 40% Coinsurance In -Network 20% Coinsurance Out -of -Network Deductible & 40% Coinsurance In -Network $0 Copayment Out -of -Network Deductible & 40% Coinsurance In -Network $0 Copayment for Medicare -covered items Out -of -Network Deductible & 40% Coinsurance $1,980 Physical and Speech Therapy Annual Benefit Maximum. This limit is for 2017 and subject to change by Medicare in 2018. $1,980 Occupational Therapy Annual Benefit Maximum. This limit is for 2017 and subject to change by Medicare in 2018. In -Network $40 Copayment for each visit Out -of -Network Deductible & 40% Coinsurance In -Network $40 Copayment for each visit Out -of -Network Deductible & 40% Coinsurance In -Network $30 Copayment for each visit Out -of -Network Deductible & 40% Coinsurance In-Network/Out-of-Network 20% Coinsurance In -Network • $250 Copayment each day for day(s) 1-7 for a Medicare -covered stay in a network hospital • After the 7th day, the plan pays 100% of covered expenses per stay Out -of -Network Deductible & 40% Coinsurance Y0011 33939 0817 EGWP C: 09/2017 4