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Mar 14 03 02:40p Diemert & Rssociates (440)442-0825 p.4 <br />Muyfield VOlage - Medfeesa„X plan besi,gn <br />Benefit Comparisou Reuewal vs. Curren,t pYsn <br /> Covered Eeuef"r#e . . <br />Renewal'-'l'lari. . <br />. <br />Cur'*ena Plan ... . : .. ... ... . <br /> ' • NetWOrk ;N'on Netrvqr,k ' Network :Non Networlt <br /> beductibie SingYexstUtily) 1Vone ' ;$300/?6Q0 • None • 1s$3001 <br />S600 <br /> (APPlies oirly to percent (!%) co,paymrenr) ' . ' . . . • , <br />. <br /> Ou?of pocketMaximum (Siz?te?Famiiy $500/S1,000 ;g1,00o1$2,000 $5001$1,000 41,000I$2;o00 <br /> Physician Qf£cce Services , ' - <br />. . , <br /> Tncluding Office Swrgeries, a'llergy . <br />' <br /> seivm and injections' . $5 • ' ' :30% • S5 ' ?30% • , . <br />. Al <br />ergy testing • Covered ;30% ' Covered <br /> <br /> <br /> Yreventive Care , . . <br />MedicalIEstory <br />Mammoj?raphy, .Peivic Exarns, .Pap . ' <br />Testing &iidPSA Teshs . $5 ' ;30% <br />Immunizations • . • _ . . <br />Annual diabet?c eye ezaffic <br />A=UW VaSI.OTI dIld H0$I111g ERBtA$ . - . • <br />azXtpntiemt P6yseiaY Medfciue Tltex?apies' CQpaymenrs based =Copaymerus based <br />(Combined NerwoYk 8c Nozl-Network limifs apply) on lace n service =o» lace o, service ? <br />Ptys,icaUOccupationa[ therapy <br />Spinal maniptklatians; ' ; ' <br />.. . <br />- ' ? , <br />, , ? <br />60160 visit limit ? • <br />: 60/60 visit li?nit <br /> <br />S eeck thetaa: . 12 visit limit <br />20 visit Liqi <br />it 112 visit liu?t . <br />20 visit li <br />xt 12 visic Iituar ? 12 visit limit. <br />" <br /> . <br />. 1 <br />At 20 visit liulit s20 visit litnit - <br />InpatYeat Setwices Covered in Full 130% • Govered in F,Il _30% <br />Unlirnited days except for. <br />Netwark/Non N'eitiW'ork combinect for 60 dayg - • <br />- . <br />physical meaicine/mhab ' . <br />Networ!'r/Non-Network eombzzAed <br />. 180 days • ? • <br />. • <br />. <br />for slci,Red nursing Pacili ` <br />? <br />optpatieat Surgery Hospzta YternaEirre . <br />' <br />' Covemd it1 Full :30% <br />' Covexed xn Fuli ; 30% <br />' <br />Care F <br />ACiCyty. • . <br />In atient aud Uutpatient T'roXess'tottal Charges Covered in M • ?30%0 . ' vered in. ?ltX? <br />?ouie Care Services . ' . , . ' ' <br />Non-N'etworklimitFarT?oxtxeCare, 30'visits !30%'. . ?sits ' <br />t ?30% <br /> Cowexed m Full vered ul k?`u <br />J?ospiee 5erviees Covered iu R11T Cp?vemd in FuH vered ?in ?u11 <br />o l <br />' <br />; Coveret! in FtullEXHIBIT <br />? <br />? <br />a <br />? <br />A