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City of Lakewood : Plan 'l Coveiira!!Ie Il irrn,cL OMYV2017 11 V311 M 17 <br /> Summary oflBenefits and Coverage: What,This Plan Covers&What it Costs Coveragefor: Single(I Plan Type:: P120 <br /> III 111� I III I'll <br /> Mantalffiehavioral I wipationt Benefits paid I on corresponding medical benefits -------name- --- <br /> serwicres <br /> one------- <br /> sprwces <br /> MantaYBehavioral I inpatient Benefits paid I an corresponding medical ben-fits -------name- --- <br /> se,rwices <br /> oin-------- <br /> servi'LW <br /> Substance use disudProutpatiert Benefits paid I an corresponding medical benefits -------name- --- <br /> mrwices <br /> oin-------- <br /> mrwcas(alcohidlism) <br /> If you have mental heallth, 'bstance use diwder outpatient Benefits paid based on corresponding medical benefits --------I <br /> behavioral heallth,or Illrkes(dirug use) <br /> substance albuse needs Substance use diwder impatient Benefits paid based on corresponding medical benefits --------I <br /> sprwces(alcoh(I <br /> Substance use disorder inpatent Benefits paid based an corresponding medical benefits -------noirre------- <br /> sprwceq(dirug use) <br /> If you are pregnant Prenatal,and paI care No charge after deductible 30%cGinsuraine -------noire-------- <br /> Delivery and all inpatient services INN charge after deductible 30%cGinsuramp ------nus ra------- <br /> If ou need helrecovering <br /> Home health car- No charqp after deductible -------noin-------- <br /> yp <br /> or have other speciall health Rehabilitation services(Physical No charge after do-ductible 30%cGinsurairicp -------noin-------- <br /> needs Therapyp <br /> Habditation services(OccaulpatwaIl I charge after deductible 30%caro ural --------I <br /> Therall <br /> Hablitaticin services(Speech I charge after deductible 30%cain3ural nce -------noir,-------- <br /> Therapy) <br /> Skilled nursing care 20%coinsurance -------nal e------- <br /> DurablP medical equipment 20%c6nsurance -------noin-------- <br /> Hospice service No charqp after deductible -------noin-------- <br /> Eye exam t,Child) No charge 30%cGinsuranP -------noine------- <br /> If your child needs dental or Glasses Not Covefed Exdluded Service <br /> eye care Dental check-up(Child) Not Covefed Exdluded Service <br /> 32 <br />