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04/26/2004 MON 16;25 FAX 440 442 5077 MV BERG DEPT <br />~] 002/004 <br />1~n~them~ <br />Blue Acee.~sSM (PFO) <br />Summary of Be~e~ts, .Effective 04/01444 <br /> <br />DedtrctiWe (singtoiFamily) None s3oo~3soo <br />fes ~, ~ -~ eats <br />out of-Pocket >l~~am~~ (~n9ie~amily) y~oo~.iooo sl.ooo~2.000 <br />Physician Oflice Services $5 ~1% <br />Inducting Ot~ioe Surgeries. allergy serer and injectionsi <br />• All tssti Covered in foil 309b <br />Preverdive Care $5 30~, <br />Meciica] History <br />Marrartographyr, Peh-ic l~cat~u, Pap testing and PSA lesls <br />Imntun$~tiotts+ <br />Atrttuai diabetic eYe eocatn <br />Mnual Vrsion and Hearing exams <br />Qulpatierrt Phvsfca! 6ledldne'ffcerapies (Combined Network & <br />N <br />N <br />t <br />k <br />ft <br />1 ~ based on pia08 of seru+ce ~yments based an place of service <br />anr <br />e <br />war <br />rm <br />s sPP <br />7~ <br />FhysipUOccupatlorral therapy: ZO120 visit limit <br />Spinal manipulations 12 visit limit <br />Speech therapy. 20 visit IimR <br />Inpatient Services Covered in full 30°6 <br />UnlfmIfecf days except for. <br />60 days iVetrvorkMon-Nedn~oric oomhined fq' <br />physical medianelrehab <br />18(1 days Netw~tslNOM~tetwoalc OombEned [or <br />skated nursin tacit <br />Oupatient Sur+geiy HospitaUAlternal;ive Care Facilky Covered In full 30°Jo <br />Other Outpatient Services Flospitat/Altertratlve Car+~ Fsd"Iity Cavard in fuG 3096 <br />Inpatient artd Qutpatietrt Profassionat Charges Coven>d (n fuA 30% <br />Home Care Services Covered in full 30% <br />3d vrits norrrnetvwrtc limit for Horne Cane exofudes N <br />t~arpiCC ServiCBS Cavcred in full Covered in fuA <br />F.ntergencyand Urgent Care: <br />Etrrergenry Cana in c7/ Room ~0 $,0 <br />Nvers all services, copaymern ~rralvedlfa~nHled. <br />irrpatlerrt Copa~mrenf apAlles) <br />Urgent Care Fadlity S35 $35 <br />Ambulance Services Covered in foil Coveted in fuA <br />!K Services Cotrered In full 3096 <br />Mental Health and Substance Alause~ (limits and <br />rr~aramurns apply) Coveted in fuA 3096 <br />Inpatient 30 Network days <br />• (ndudes inpatient merrlal health Non•Nelwork) CoQaymenfs cased on place of setylce Copayrrrents Lased on place of service <br />outpatient 30 Network visits <br />10 Non~Jefwork mental health visit <br />Inpatient and otdpatierrt subslanee abuse $550 NorMietwork <br />Substance abnsa rrhab!!rtafion p-agr~rrs ere 6m~ed fo two per <br />time Network and Na-r-Network camluoed.) <br />C_ al! 7~7884U03 fnr ar~lhoriied reterrg! <br />fetimo Maximum (Combined Network and Non-Netwark) S5 million S5 million <br />Mf!<emwie ctaesxie~lue 9Ne6d Iefn~vadenenw ~Coaxnanij~ hwuarrw Comyairy. <br />Mayfield Village <br />