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Appendix A <br /> <br />e??fl?? <br />1\/t E D] Ch L City of North Oimsted sup ??! <br />M U T U A L_ SuperMed 80%120% Pius Plan <br />(---, Plks` <br />Benefits F Network -Non-Network <br />Benefit Period January 15 through December 315 <br />Dependent Age Limit 19 Dependent / 25 Studenf <br />Removal u on Birth Date <br />Pre-Existin Condition Waitin Period No Subject to Pre-Ex <br />Blood Pint Deductible Q ints <br />Lifefime Maximum $2,500,000 <br />Benefit Period Deductibie - Sin le/Famil $200 / $400 $400 / $800 <br />Coinsurance 80% 60% <br />Coinsurance Out-of-Pocket Maximum <br />Excfudin Deductible - Sin lelFamil $1,000 / $2,000 $2,000 / $4,000 <br />Ph sician)Office Services <br />Office Visit lllness/ln'ur 80% after deductible 60% after deductible <br />Ur ent Care Office Visit 80% after deductible 60% after deductible <br />Voluntar Second Sur ical O inion 80% after deductible 60% after deductible <br />Aller Testin and Treatments 80% after deductible 60% after deductible <br />All Irnmun'izations includin Routine 80% after deductibie Not Covered <br />Preventative Services <br />Office VisiURoutine Physical Exam <br />One exarn er benefit eriod 80% after deducfibie Not Covered <br />Well Child Care Services incfuding Exam and <br />immunizations to a e nine Sd% after deductible Not Covered <br />Well Child Care Laborator Tests (to a e 9 100% <br />Routine Mammo ram one er benefit eriod 10D% <br />Routine Pa Test one er benefit eriod 10D% <br />Routine EKG, Chest X-ray, Complete Blood <br />Count, Comprehensive Metabolic Panel, <br />Urinal sis 10D% <br />Out atisnt Services <br />Sur ica! Services 80% after deductible 60% after deductible <br />Dia nostic Services 10 D% <br />Physical/Occupational Therapy - Faciiity and <br />Professional 10 visits then Med Review 80% after deductible 60% after deductible <br />Chiropractic Therapy - Professionai Only <br />Unlimite 80°!o after deductible 60% after deductible <br />Speech Therapy - Facility and Professional <br />(10 visits then Med Review 80°!o after deductible 60% after deductible <br />Cardiac Rehabilitation 80% after deductibie 60% after deductible <br />Emer enc use of an Emer enc Room $50 Co a, then 100% <br />Non-Emergency use of an Emergency <br />Room2,3 $50 Copay, then SO% $50 Copay, then 60% <br />?3