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Nate E O 1! In the pursuit of health Indian River County BOCC #90000 2015 BlueMedicare Group PPO* (Employer PPO) Health Benefits Benefits l BlueMedicare Group PPO* Plan 1::, Premium (per member, per month) $319.92 for PPO1Rx1 Annual Deductible (DED) $0 In -Network / $1,000 Out -of -Network Out -of Pocket Maximum (based on plan year) $1,000 In -Network / $3,000 Out -of -Network In -Network out-of-pocket maximum accumulates toward axim O1 ut-of-N... ey4two;rk out- o,•.f-poc. ket-;1m ezfer -4,%a -y*x : PhysicianOffiee • �:4 = �. 1�t'i_is,.LN:"2Aii. - . Num v.„. ff.. As,- -<J'Y .rdv � —0. _A '''-r4- ' c 1-5' L" � : b'l 1 ncv, v4�,; w.s_� ;xn::'C:�v�sfek.w Primary Care (per visit) In -Network $10 Copayment Out -of -Network DED & 20% Coinsurance Specialist Care (per visit) In -Network $30 Copayment Out -of -Network DED & 20% Coinsurance e -Visit In -Network $5 Copayment Out -of -Network DED & 20% Coinsurance Convenient Care Center In -Network / Out -of -Network $30 Copayment Podiatry Services (per visit) (routine foot care up to 6 visitsper year) In -Network $30 Copayment Out -of -Network DED & 20% Coinsurance Chiropractic Services (per visit) For each Medicare -covered visit (manual manipulation of the spine to correct subluxation) In -Network $20 Copayment Opt -of -Network DED & 20% Coinsurance Outpatient Mental Health Care (per visit) For individual or group therapy (including partial hospitalization) In -Network $35 Copayment Out -of -Network DED & 20% Coinsurance Outpatient Substance Abuse Care (per visit) In -Network $35 Copayment Out -of -Network DED & 20% Coinsurance - Part B Drugs (including chemotherapy) In -Network 20% Coinsurance Out -of -Network DED & 20% Coinsurance Allergy Injections In -Network $5 Copayment Out -of -Network DED & 20% Coinsurance Y0011_31874 0414R4 EGWP C 06/2014 1