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In the pursuit of health <br />Benefits <br />w ,•? <br />-FS*' :r +,�.•,--, '.''�3; <br />ER�s ical Seruices.ari Sau�pplies <br />titaRrifi'' <br />'J+_ v.ta, K wst 44�? x�_,^-'": _,,, t .� _+_c 'm4,, Li '. fhr.�x~'.f�'"�j <br />. <br />BlueMedicare Group PPO* Plan 1 <br />Ea rJs Azsh <br />"� } w.u�``�+ o y�;,._ <br />t - - <br />a..ha. Y+fs .?�?.r�:?..�" �` _ 7•.:'.,t' �'i� `_. R� . t :i..e' :o`Y. " t .' vrsEo- ' C,.. a,•3} <br />Durable Medical Equipment/Diabetic <br />Supplies <br />Diabetic Supplies (glucose meters, test strips <br />and lancets) <br />Note. needles, syringes and insulin for self - <br />injection are covered under your Part D <br />benefit <br />Equipment: Plan -Approved Electric <br />Customized Wheelchairs, Electric Scooters <br />All Other Medicare -Covered Durable Medical <br />Equipment <br />In -Network $0 Copayment <br />Out -of -Network DED & 20% Coinsurance <br />In -Network 20% Coinsurance <br />Out -of -Network DED & 20% Coinsurance <br />In -Network $0 Copayment <br />Out -of -Network DED & 20% Coinsurance <br />Prosthetic Devices <br />In -Network $0 Copayment for Medicare -covered <br />items <br />Out -of -Network DED & 20% Coinsurance <br />Outpatient Rehabilitation <br />Occupational Therapy, Physical Therapy, <br />Speech & Language Therapy, Cardiac and <br />Pulmonary Rehab (including intensive <br />cardiac rehab) <br />Office or Freestanding Facility <br />Services <br />Outpatient Hospital Services <br />Dialysis <br />In -Network $30 Copayment for each visit <br />Out -of -Network DED & 20% Coinsurance <br />In' -Network $30 Copayment for each visit <br />Out -of -Network DED & 20% Coinsurance <br />In-Network/Out-of-Network 20% Coinsurance <br />_ �r �3 <br />:s4 R; :.s ;W 7-;ja e:i t ,r .: i`,:`7-'; �Z.. <br />a a a, 7 <br />:-,� <br />.s /n� �r '�.' i%YraVi..:g- i.13 <br />Irat ii."• = <br />P,+eS''vvk . ��, 4,,:; ' t , <br />8 n 15911=.�.I�a,1e : a1 'fin;. • ;rat"' <br />::Z.e'�-r.0 }.-'lavY�•-',:ice`,_"'JS=:':'ice3._v?�:ti`4H`�:'k:�9' .."..'.tt at:�fl'i' <br />mow: - ,�.,�: <br />:-. '' ;k.iA ice .,.,-. =. <br />1� _,-•, _ <br />,:. �e a a.; „- <br />.�'.' -.J }; E:-.' <br />-sem.. .. 3c;...-,:"Il- <br />,� <br />k•`s:fA._'''''a.; ' .•-• ., is i . "Il ire "' -, 4 7y .^L -* ._ <br />i..�i�w�t'�:.��.(.:oi�ai-�"ai��:c.`.c'Z.�.'1vl+c-i'-::�Y�:u:1�.r'+U:.(•�:k.: .Yhtt :IFJ',��'3�-t�d..s�. <br />Inpatient Hospital Care <br />(including substance abuse treatment) <br />In -Network <br />• $150 Copayment each day for day(s) 1-7 <br />for a Medicare -covered stay in a network <br />hospital <br />• After the 7th day, the plan pays 100% of <br />covered expenses per stay <br />Out -of -Network DED & 20% Coinsurance <br />Y0011_31874 0414R4 EGWP C. 06/2014 <br />4 <br />