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Vaccines (Medicare -covered) In -Network <br />upplemental Benefit <br />Fitness <br />• $0 Copayment for influenza vaccine <br />• $0 Copayment for pneumococcal vaccine <br />• $0 Copayment for hepatitis B vaccine <br />Out -of -Network 40% Coinsurance <br />Free membership through SilverSneakers <br />BlueMedicare Group PPO out-of-pocket maximum includes all covered health services member cost <br />share rendered in/out of network on a Plan Year basis. Supplemental services and Part D costs are <br />not applied to out-of-pocket maximum. <br />Medicare Part B - the premium provided under this plan excludes the Medicare Part B premium <br />payments. (Members must continue to pay the Medicare Part B premium unless paid by Medicaid or <br />another third party.) <br />Florida Blue is a PPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract <br />renewal. <br />Y0011 33939 0817 EGWP C: 09/2017 6 <br />