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Benefits Network A?-Non-Networlc In atient Facilit Semi-Private Room and Board 80% after deductible I 601/c, after deductible ? IVlaternit 80% after deductible 60% after deductible SkiEled Nursing Faciiity (100 days per benefit eriod 80% after deductible 60% after deductible Additional Services Ambutance 80% after deductible 60% after deductible Durable Medica! E ui ment, Prosthetics 80% after deductible 60% after deductible ' Home Healthcare 80°/o after daductible Not Covered Hos ice 80% after deductible Not Covered Or an Trans lants Private Dut Nursin 80% after deductible 80% after deductible 60% after deductible ? 60% after deductible , Mental Health and Substance Abuse j Inpatient Mental Health and Substance Abuse Services (30 days per admission; Subsfance Abuse lirnited to one admission per benefif eriod 50% after deductible Not Covered ? Outpatient Mental Health and Substance Abuse Services (20 visits er benefit eriod 50% after deductible 50% after deductible Note: Services requiring a copyament are not subject to the single/family deductible. Coinsurance expenses incurred for services by a non-network provider will also apply to the network coinsurance out-of-pocket limits. Coinsurance expenses incurred for services by a network providar wiil also apply to the non- network coinsurance out-of-pocket limits. Non-Contracting and Facility Other Providers will pay the same as Non-Network. Benefits will be determined based on Medical Mutual's medical and administrative policies and procedures. This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an afficer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete fisting of covered services. In certain instances, Medica! Mutua!'s payment may not equal the percentage listed above. However, the covered person's coinsurance will always be based on the lesser of the provider's billed charges or Medical Mutual's negotiated rate with the provider. Maximum famify deductible. Member deductible is the same as single deductible. 3-month carryover applies. ZCopay waived if admitted. 3The copay appfies to room charges onty. All other covered charges are subject to deductible and coinsurance. 4Not applied to Coinsurance Out-of-Pocket Maximum 4-1-05 Dpl 2 Plus ?l;