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Florida, Blue <br />In the pursuit of health <br />Indian River County BOCC #90000 <br />2019 BlueMedicare Group PPO (Employer PPO) Health Benefits <br />Benefits <br />BlueMedicare Group PPO Plan 2 <br />Premium (per member, per month) <br />Annual Deductible <br />Out -of -Pocket Maximum <br />(based on plan year) <br />hysician Offic <br />Primary Care (per visit) <br />Specialist Care (per visit) <br />$295.11 for PPO2Rx1 <br />$0 In -Network / $2,000 Out -of -Network <br />$2,000 In -Network / $4,000 Out -of -Network <br />In -Network out-of-pocket maximum accumulates <br />toward Out -of -Network out-of-pocket maximum <br />In -Network $35 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />In -Network $50 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />Convenient Care Center <br />Podiatry Services (per visit) <br />(routine foot care up to 6 visits per year) <br />Chiropractic Services (per visit) <br />For each Medicare -covered visit (manual <br />manipulation of the spine to correct <br />subluxation) <br />Outpatient Mental Health Care (per visit) <br />For individual or group therapy <br />(including partial hospitalization) <br />Outpatient Substance Abuse Care <br />(per visit) <br />In -Network / Out -of -Network $50 Copayment <br />In -Network $50 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />In -Network $20 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />Part B drugs (including chemotherapy) <br />Allergy Serums for Injection <br />In -Network $40 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />In -Network $40 Copayment <br />Out -of -Network Deductible & <br />In -Network 20% coinsurance <br />Out -of -Network Deductible & <br />40% Coinsurance <br />40% Coinsurance <br />In -Network $10 Copayment <br />Out -of -Network Deductible & 40% Coinsurance <br />Y0011 34432 M 0918 EGWP C: 09/2018 1 <br />