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Benefits BlueMedicare Group PPO Plan 2 Outpatient Hospital Services (per visit) Occupational Therapy, Physical Therapy, Speech & Language Therapy, Cardiac Rehab (including intensive cardiac rehab) Pulmonary Rehab Radiation Therapy Dialysis Lab Only All Other Diagnostic Tests, X -Rays, Advanced Imaging, etc. Urgently Needed Care (This is not emergency care, and in most cases is out -of -the -service area.) Emergency Services (Including Worldwide Coverage) Medicare -Covered Dental, Hearing and Vision Home Health Ambulance In -Network $40 Copayment Out -of -Network Deductible & 40% Coinsurance In -Network $30 Copayment Out -of -Network Deductible & 40% Coinsurance 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 In -Network $50 Copayment Out -of -Network Deductible & 40% Coinsurance In -Network / Out -of -Network 20% Coinsurance In -Network $30 Copayment Out -of -Network Deductible & 40% Coinsurance In -Network $250 Copayment Out -of -Network Deductible & 40% Coinsurance In -Network / Out -of -Network $50 Copayment In -Network / Out -of -Network $75 Copayment ($25,000 maximum per plan year for worldwide emergency services received outside the U.S.) In -Network $50 Copayment Out -of -Network Deductible & 40% Coinsurance In -Network / Out -of -Network $0 Copayment In -Network / Out -of -Network $150 Copayment for Medicare -covered ambulance services Equipment: Plan -Approved Electric Customized Wheelchairs, Electric Scooters All Other Medicare -Covered Durable Medical Equipment Y0011 34432 M 0918 EGWP C: 09/2018 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 3