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Inpatient Mental Health Care <br />Skilled Nursing Facility <br />(in a Medicare -certified skilled nursing <br />facility) <br />Hospice <br />Preventive Services <br />16 <br />In-Network <br />• $250 Copayment each day for day(s) 1-7 for <br />a Medicare -covered stay in a network <br />hospital <br />• $0 Copayment each day for day(s) 8-90 for a <br />Medicare -covered stay in a network hospital <br />• 190 -day lifetime limit in a psychiatric hospital <br />Out -of -Network Deductible & 40% Coinsurance <br />In -Network <br />• $0 Copayment each day for days 1-20 per <br />benefit period <br />• $100 Copayment 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 Deductible & 40% Coinsurance <br />Member must receive care from a Medicare -certified <br />hospice <br />Annual Screening Mammograms In -Network $0 Copayment for Medicare -covered <br />(for women with Medicare, age 40 and older) screening mammograms <br />Out -of -Network 40% Coinsurance <br />Pap Smears and Pelvic Exams <br />(for women with Medicare) <br />Bone Mass Measurement <br />(for people with Medicare who are at risk) <br />In -Network <br />• $0 Copayment per pap smear <br />• $0 Copayment per pelvic exam <br />Out -of -Network 40% Coinsurance <br />In -Network $0 Copayment for each Medicare - <br />covered bone mass measurement <br />Out -of -Network 40% Coinsurance <br />Colorectal Screening Exams In -Network $0 Copayment for Medicare -covered <br />(for people with Medicare age 50 and older) colorectal screening exams <br />Out -of -Network 40% Coinsurance <br />Prostate Cancer Screening Exams <br />(for men with Medicare age 50 and older) <br />In -Network $0 Copayment for Medicare -covered <br />prostate cancer screening exams <br />Out -of -Network 40% Coinsurance <br />Y0011 33939 0817 EGWP C: 09/2017 5 <br />