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APPENDIX A <br />~, 1~~ E D 1 CA L Gi~cy of l~orfh Ofms~:ed p~~ ~~ <br />t~~ U T U A L,,, Super~Vled 80%120% Plus Plan ~,./ x,1,15. <br />Benefits C~ Network ~~-Non-Network <br />Benefit Period January 1s1 through December 315' <br />Dependent Age Limit 19 Dependent / 25 Student <br /> Removal upon Birth Date ____ <br />Pre-Existing Condition Waitin Period _ No Subject to Pre-Ex _ <br />Blood Pint Deductible 0 pints <br />Lifetime Maximum $2,500,000 <br />Benefit Period Deductible -Sin le/Famil ~ $200 / 9400 9400 / $800 <br />Coinsurance 80% GO% <br />Coinsurance Out-of-Pocket (Maximum 91,000 I $2,000 $2,000 / 94,000 <br />Excludin Deductible -Sin le/Famil <br />Ph sicianlOffice Services <br />Office Visit (Illness/ln'ur <br />80% after deductible <br />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 />Alter Testin and Treatments 80% after deductible GO% after deductible <br />All Immunizations (includin Routine 80% after deductible Not Covered <br />Preventative Services <br />Office VisitlRoutine Physical Exam 80% after deductible Not Covered <br />(One exam er benefit eriod) <br />Well Child Care Services including Exam and I <br />80% after deductible <br />Not Covered <br />Immunizations (to a e nine <br />Nell Child Care Laborator Tests to a e 9 100% <br />Routine Mammo ram (one er benefit eriod 100% <br />Routine Pa Test one er benefit eriod 100% <br />Routine EKG, Chest X-ray, Complete Blood 100% <br />Count, Comprehensive Metabolic Panel, <br />Urinal sis <br /> <br />Out afient Services <br />Sur ical Services 8D% after deductible 60% after deductible <br />Dia nostic Services 100% <br />Physical/Occupational Therapy -Facility and 80% after deductible GO% after deductible <br />Professional 10 visits then Med Review <br />Chiropractic Tl~erapy -Professional Only 80% after deductible GO% after deductible <br />Unlimite <br />Speech Therapy -Facility and Professional 80% after deductible 60% after deductible <br />10 visits then Med Review <br /> Cardiac Rehabilitation 80% after deductible 60% after deductible <br /> Emergency use of an Emergency Room $50 Co a ,then 100% <br /> Non-Emergency use of an Emergency 950 Copay ,then 80% 950 Copay ,then GO% <br /> Room~'3 <br />