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11.11.1111111111111111111111111111 BlueMedicare Group PPO Plan 2 Prosthetic. Devices In -Network $0 Copayment for Medicare -covered items Out -of -Network Deductible & 40% Coinsurance 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 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 Dialysis In-Network/Out-of-Network 20% Coinsurance InpatientCare Inpatient Hospital Care (including substance abuse treatment) 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 Inpatient. Mental Health Care (in a certified psychiatric facility) 190 -day lifetime limit in a psychiatric hospital In -Network • $250 Copayment each day for day(s) 1-7 for a Medicare -covered stay in a network hospital • $0 Copayment each day for day(s) 8-90 for a Medicare -covered stay in a network hospital Out -of -Network Deductible & 40%Coinsurance Skilled Nursing Facility (in a Medicare -certified skilled nursing facility) There is a limit of 100 days for each benefit period 3 -day prior hospital stay is not required In -Network • $0 Copayment each day for days 1-20 per benefit period • $100 Copayment each day for days 21-100 per benefit period Out -of -Network Deductible & 40% Coinsurance Hospice Member must receive care from a Medicare -certified hospice Y0011 34432 M 0918 EGW P 'C: 09/2018 71 4