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In the pursuit of health <br />Benefits <br />Outpatient Hospital Services (per visit): <br />Occupational Therapy, Physical Therapy, <br />Speech & Language Therapy, Cardiac and <br />Pulmonary Rehab (including intensive <br />cardiac rehab) <br />Radiation Therapy <br />Dialysis <br />Lab Only <br />All Other Diagnostic Tests, X -Rays, <br />Advanced Imaging, etc <br />BlueMedicare_Group PPO* Plan 1 <br />In -Network $30 Copayment <br />Out -of -Network DED & 20% Coinsurance <br />In -Network $50 Copayment <br />Out -of -Network DED & 20% Coinsurance <br />In -Network / Out -of -Network 20% Coinsurance <br />In -Network $15 Copayment <br />Out -of -Network DED & 20% Coinsurance <br />In -Network $150 Copayment <br />Out -of -Network DED & 20% Coinsurance <br />Urgently Needed Care <br />(This is not emergency care, and in most <br />cases is out -of -the -service area ) <br />In -Network / Out -of -Network $30 Copayment <br />Emergency Services <br />In -Network / Out -of -Network $50 Copayment <br />Worldwide Coverage <br />Dental, Hearing and Vision (Medicare - <br />Covered) <br />In -Network $30 Copayment <br />Out -of -Network DED & 20% Coinsurance <br />Home Health <br />In -Network / Out -of -Network $0 Copayment <br />Ambulance <br />In -Network / Out -of -Network $150 Copayment for <br />Medicare -covered ambulance services <br />Y0011_31874 0414R4 EGWP C 06/2014 3 <br />