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Mar 14 03 02:40p Diemert & Rssociates 14401442-0825 p.5 <br /> <br /> Emergenc•y and UrgvnE Care? . , ' <br /> Emergency carE in Emergency Room $50 i$50 . <br />$50 <br /> (covers all servrces, copayment waived rf <br />_ . '$SU <br /> admirte4 then r'npatient copcrymW applies) . ; ' . ? <br /> Urgent Care FacxJ.ity ' ' • $35 <br />$35 '30% <br /> . <br /> Ambulance Sex-VRces ' . Covmd in FulF :Covercd i? Cpvered in FuIl ;Covered in pili. • ' <br /> Maternit Serviees . CoYered {ri Ft?' ' =0% ' Co?vered ' - o <br />? ?11 :$0% • , <br /> Mental Health/Sqbstance Abuse (LjUaptg a1ad : ------------- <br /> maximuras aPPLY) . • ' <br /> <br />; <br />• . <br /> .Inpatient ,i . . . <br /> (l,ncludes iaipatienit mental Heatth Non-Netwo*) 30 days - <br /> <br /> <br />' <br /> <br />Outpatient: • 30 day$ <br />• <br />Covered in Full ?1 ." , Coyered in k?t11 :50 /o <br />?. <br /> . . . Copayment,v based `Copayments 8crsed ' <br /> 10 Non-Neiwork mental f?ealrh ?chisxts - WUlm= e o sice <br />' '1 SO <br />i <br />i . <br /> • ' $550 - v <br />s <br />ts <br />;Based on place of <br />t apatiezxt aRd oufpafient substance abuss • F <br />s'$550 ? ' Fsezvice <br />, <br />., ubstance abuse 1-ehct'biritation progrrnns • =$SSO <br />, Substance abure rehabilitation <br />• vre lim?ited to tlvo pcr Cifetinre NetWOrk <br />and Non Nerivork co'irr$in?d •' 1?ogrmns arg jjmitsd to hvo per I{?'eLime <br /> etwork andNon Netwotk combined • ' <br />?Tamau Orgare and Mmite Transplaut.s . • . <br />e?ce?t Kit4Otey and Comea ugttsplaats. A ' ; <br />? . <br />f ` ' . <br /> <br />separste $ liniilian 1ifbbtzue Maximum applic3s. <br />(Coaibixiecl Netwozk and Non Neta+ork) • <br />. . . <br />coverea in bl?I1 =50% • <br />. . ; . , <br />a . <br />= . <br />Covened in ?till ' ; 50% ' <br />. . <br />Medical Snpplies, E uip!"eOt.and T liances 20% `40°/ <br /> <br />. a <br />. 209io . a? <br /> <br />:4 <br />0 /o . <br />Prescriptio't1 Drug Options: ' <br />Neiwork ReiW ?'harmacies: <br />(30 daY supPly) ' $8G2nForm/?I•S?xat? <br />SO%,rni?c ?30 <br />' • ` . <br />$BGenFonw/$ISBr?50%; mrn $90 <br />' Tnciudes diabe?c te,at stzip Form $25 N <br />oa Fo?; <br />: ? . F?Tm ?5 Non Fo?i ' <br />Ric Airect Mail Sexvice <br />. . ' • ? . ' . ' • ; . . ' <br />(90 day supplq) . . <br />ir,tcludes diabetie test str' ' $164enFerm/$3013r?Kot Covexed : . . <br />$16QxeuForm1$30B4Not Cover <br />d <br />. Folm $50 Non Ppmi e <br />Form $SO N'on Form <br />Liletime Maaimum (Combined Netwox?c/ <br />Non'Network ' <br />. $5 milHon ;$S million <br />? . $5 mdllion? =''?5•mitlion <br />. <br />. ? , .