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In -Network Out -of -Network <br />Ambulatory • $200 copay for surgery services 40% of the Medicare -allowed <br />Surgical Center provided at an Ambulatory amount after $2,000 <br />(ASC) Services Surgical Center 0 out -of -network deductible <br />• $0 copay for diagnostic <br />colonoscopy <br />Doctor Visits • $25 copay per provider of choice <br />visit <br />• $45 copay per specialist visit <br />■ 40% of the Medicare -allowed <br />amount after $2,000 <br />out -of -network deductible <br />Preventive Care - $0 copay <br />- 40% of the Medicare -allowed <br />• Abdominal aortic aneurysm <br />amount <br />screening <br />• Annual wellness visit <br />• Bone mass measurement <br />• Breast cancer screening <br />(mammograms) <br />• Cardiovascular disease risk <br />reduction visit (therapy for <br />cardiovascular disease) <br />• Cardiovascular disease testing <br />• Cervical and vaginal cancer <br />screening <br />• Colorectal cancer screening <br />• Depression screening <br />• Diabetes screening <br />• Diabetes self-management <br />training, diabetic services and <br />supplies <br />• Health and wellness education <br />programs <br />• Hepatitis C Screening <br />• HIV screening <br />• Immunizations <br />• Medical nutrition therapy <br />• Medicare Diabetes Prevention <br />Program (MDPP) <br />• Obesity screening and therapy <br />to promote sustained weight <br />loss <br />5 <br />