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Y U, <br /> 2 C,) �)Iaiirii 4(''Id"i AS(IPAIII <br /> In�{V C 0 V i a q 0 to:i I i)q 11 I l'Y I I 1 11 Ll n I YP c,:: 1,li,1( <br /> iihlll VIII* <br /> Emergency room services. No charge after deductible ------none------- <br /> If you <br /> ---nons,------- <br /> Ifyou need immediate Emergency medical transportation 1M6 cc insurance 30%co-insurarce none <br /> medical ------- <br /> medical attention <br /> Urgent care 10%cc-insurance 30%co-insurarce _---nons,------- <br /> If vau have a hoanital stav Facility fee(e.g.,hospital room): 10%coinsurance 30%coinsurance none------- <br /> Physician/surgeon fee(inpatient) 10%co insurance 30%co-insurance ------- <br /> Mental/Behavioral health outpatient Benefits paid based or corresponding medical benefits ------- <br /> services. <br /> Ment allBehav i oral health inpatient Benefits paid based on corresponding medical benefits -------none------ <br /> services nors`______services <br /> Substance abuse disorder outpatient Benefits paid based or corresponding medical benefits -------none------ <br /> services(alcoholism) <br /> If you have mental health, Substance abuse disorder outpatient Benefits paid based or corresponding medical benefits -------none------ <br /> behavioral health,or services.(drug abuse): <br /> substance abuse needs Substance abuse disorder inpatient Benefits paid based on corresponding medical benefits -------none------ <br /> services(alcoholism) <br /> Substance abuse disorder inpatient Benefits paid based on corresponding medical benefits none----- <br /> services (drug abuse) <br /> If you become pregnant Prenatal and postnatal care 10%co insurance 30%co-insurance ------- <br /> Deliveri and all inpatient services 10%co-insurance 30%co-insurarce __110re------- <br /> Home health care 10%co-insurance ------- <br /> Rehabilitation services 10%co-irsurance 30%co-insurance __--rors,------- <br /> Habilitation services.(Occupational 10%cc insurance 30%co-irsurarce -------none- --- <br /> Therapy) <br /> one------- <br /> Therapy) <br /> If need help recovering Habilitation services(Speech 10%co insurance 3,0%co insurance -------none- -- <br /> or <br /> or&------- <br /> or have other special health Themciv) <br /> Skilled nursing care 20%co-insurance -------none------ <br /> Durable medical equipment 20%co-irsurarce -------none------ <br /> Hospice <br /> nors`______Hospice Service 10%co-irsurarce ------_none----- <br /> ..um mow of i nI°';.W� �I � u�uui our � ������ � � � iiii��lllll III IIIII�•���� �i. m w.�iY� <br /> m I���� 11 .� � . . Ili a Ifll � <br /> Eyeexam <br /> -nor&-----Eyeexam Noch2rge 3t%co-insurance -------none------- <br /> If <br /> ------none------- <br /> If yourchild needs dental or Glasses Not Covered Excluded Service <br /> eye care Dental check-up(Child) Not Covered Excluded Service <br /> S <br /> Y �)kun 2 WVC) �)Iaiin '4()1`4 SII n' <br /> In C 00 V 01 q 0 ki 1 1: '1 1 r I 11, 11 a n l Y p 0! 1,1P <br /> ExClUded Services&Other Covered Services: <br /> Service Your plan Does NOT Cover(This isn't a complete list. Check your policy or plan document for other excluded services.) <br /> Acupuncture Cosmetic Surgery Dental check-up(Child) <br /> • Dental Care(Adult) • Glasses Hearing Aids <br /> Infertility Treatment Lorg-Term Care Non-emergency y care when traveling outside the <br /> U.S.. <br /> Routine Eve Care(Adult) Routine Fool Care <br /> Other Covered Services(This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) <br /> Bariatric Surgery • Chiropractic Care Private-Duty Nursing <br /> • Weight.Loss Programs <br /> 37 <br />