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&ewe C.) Kai In the pursuit of health Benefits' ' .BlueMedicare Group, PPO* Plan 1 Inpatient Mental Health Care In -Network • $200 Copayment each day for day(s) 1-7 for a Medicare -covered stay in a network hospital • $0 Copayment for day(s) 8-90 for a Medicare -covered stay in a network hospital • 190 -day lifetime limit in a psychiatric hospital Out -of -Network DED & 20% Coinsurance Skilled Nursing Facility (in a Medicare -certified skilled nursing facility) In -Network • $0 Copayment each day for days 1-20 per benefit period • $75 Copayment each day for days 21-100 per benefit period • There is a limit of 100 days for each benefit period • 3 -day prior hospital stay is not required Out -of -Network DED & 20% Coinsurance Hospice Member must receive care from a Medicare - certified hospice 't-- ;)-Y,:.(. iil�E�RFVr.•�"`�0t �'�j''`�s;"• sSa =Preuaenti,�Seryiees� - =5r_�zr��$A�str +;moyyyF 61l- y .r-w-=iE .�ic!`:�,+_. ,sS- roc_ x -a Annual Screening Mammograms (for women with Medicare, age 40 and older) In -Network $0 Copayment for Medicare -covered screening mammograms Out -of -Network 20% Coinsurance Pap Smears and Pelvic Exams (for women with Medicare) In -Network • $0 Copayment per Pap smear • $0 Copayment per pelvic exam Out -of -Network 20% Coinsurance Bone Mass Measurement (for people with Medicare who are at risk) In -Network $0 Copayment for each Medicare - covered bone mass measurement Out -of -Network 20% Coinsurance Colorectal Screening Exams (for people with Medicare age 50 and older) In -Network $0 Copayment for Medicare -covered colorectal screening exams Out -of -Network 20% Coinsurance Prostate Cancer Screening Exams (for men with Medicare age 50 and older) In -Network $0 Copayment for Medicare -covered prostate cancer screening exams Out -of -Network 20% Coinsurance Y0011_31874 0414R4 EGWP C 06/2014 5