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Benefits BlueMedicare Group PPO Plan 2 Preventive Services Annual Screening Mammograms (for women with Medicare, age 40 and older) Pap Smears and Pelvic Exams (for women with Medicare) Bone Mass Measurement (for people with Medicare who are at risk) In -Network $0 Copayment for Medicare -covered screening mammograms Out -of -Network 40% Coinsurance In -Network • $0 Copayment per pap smear • $0 Copayment per pelvic exam Out -of -Network 40% Coinsurance Colorectal Cancer Screening Exams (for people with Medicare age 50 and older) Prostate Cancer Screening Exams (for men with Medicare age 50 and older) Medicare -Covered Immunizations Supplemental Benefit In -Network $0 Copayment for each Medicare - covered bone mass measurement Out -of -Network 40% Coinsurance In -Network $0 Copayment for Medicare -covered colorectal screening exams Out -of -Network 40% Coinsurance In -Network $0 Copayment for Medicare -covered prostate cancer screening exams Out -of -Network 40% Coinsurance In -Network • $0 Copayment for influenza vaccine • $0 Copayment for pneumococcal pneumonia vaccine • $0 Copayment for hepatitis B vaccine Out -of -Network 40% Coinsurance Fitness Program Free membership through SilverSneakers BlueMedicare Group PPO out-of-pocket maximum includes all covered health services member cost share rendered in/out of network on a Plan Year basis. Supplemental services and Part D costs are not applied to medical out-of-pocket maximum. Medicare Part B - the premium provided under this plan excludes the Medicare Part B premium payments. (Members must continue to pay the Medicare Part B premium unless paid by Medicaid or another third party.) Florida Blue is a PPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal. Y0011 34432 M 0918 EGWP C: 09/2018 5