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~ Benefits Network ~~--Non-Network Inpatient Facility _ ___ ~- - ° - I 80%, after deductible ~ GO /° after deductible I i-Private Poom and Board S _ ~ em Iv'iaternity 80%~ after deductible - 60% after deductible Skilled Nursing Facility (100 days per benefit 80% after deductible GO% after deductible period} Additional Services 80% after deductible 60% after deductible Ambulance Durable I~ledical Equipment, Prosthetics _ 80% after deductible GO% after deductible Home Healthcare 80°/, after deductible _ IJot Covered Hos ice 80% after deductible Not Covered Or an Trans lants 80% after deductible GO% after deductible Private Dut Nursin 80% after deductible 60% after deductible __ Mental Health and Substance Abuse ---~ Inpatient Mental Health and Substance Abuse 50% after deductible Not Covered Services (30 days per admission; Substance Abuse limited to one admission per benefit eriod Outpatient Mental Health and Substance 50% after deductible 50% after deductible Abuse Services 20 visits er benefit eriod Note: Services requiring a copyament are not subject to the single/family deductible. Coinsurance expenses incurred for services by anon-network providerwill also apply to the network coinsurance out-of-pocket limits. Coinsurance expenses incurred for services by a network providerwill 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 officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or certificate will contain the complete listing of covered services, In certain instances, Medical Mutual'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 family deductible. Meillber deductible is the same as single deductible. 3-month carryover applies. '`Copay waived if admitted. 3The copay applies to room charges only. All other covered charges are subject to deductible and coinsurance. QNot applied to Coinsurance Out-of-Pocket Maximum 4-i-os o,r 1 Fw5