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APPENL'IY A <br />- - -- <br />,.~ 1;~I E U1 Cf~, L City of f~or~~r Qimsted ~~ <br />i~%~U T ~._!t', L .., ~uperl'Vlecl GO%/20% Plus Plan ~~ ~,/L,`, <br />(Eenefits <br />~ ~- tJetwork ~ Non-Network <br />~~ <br />i t <br />Benefi Period January 1 j' through December 81 "' <br />~ <br />_ <br />C1r~penClP.nt /7Ge Linlit <br />~ <br />19 Dependent / 25 Student <br />Removal upon Birth Date _______~ <br />~ Pre-Eristirlg Condition 1Naiting Period No Subject to Pre-Ex _~ <br />Blood Pint Deductible 0 i~ints <br />Lifetime MaXInlLlil`I $2,00,000 <br />Benefit Period Deductible -Single/rarnily~ X200 / X400 a~400 / $800 <br />Coinsurance 80% GO% <br />Coinsurance Out-of~Pocket IVlaximum <br />(Excludin Deductible -Single/Family X1,000 / X2,000 X2,000 / $4,000 <br />Ph sicianlOffice Services <br />Office Visit (Illness/Inlur) 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 />Allen Testino and Treatments SO% after deductible GO% after deductible <br />All Immunizations includin Routine 80% after deductible Not Covered <br />Preventative Services <br />Office Visit~Routine Physical Exam <br />(One exam er benefit eriod 80% after deductible I Not Covered <br />Nell Child Care Services including Exam and <br />Immunizations (to a e nine 80% after deductible I Not Covered <br />1Nell Child Care Laboratory Tests to a e 9 100°ro <br />Routine Mammogram (one er bener'it eriod 10D% <br />Routine Pap Test one er benefit eriod 10D°ro <br />P.outine EKG, Chest X-ray, Complete Blood <br />Count, Comprehensive Metabolic Panel, <br />UrlnalYSlS 100% <br />', <br />Out anent Services <br />Sur ical Services 80% after deductible 60% after deductible <br />Diagnostic Services 100 % <br />Physical/Occupational Therapy -Facility and <br />Professional 10 visits then Med Review 80% after deductible GO% after deductible <br />Chiropractic Therapy -Professional Only <br />Unlimite 80% after deductible GO°!° after deductible <br />Speech Tflerapy -Facility and Professional <br />l10 visits thel ~ IVled Review 80% after deductible GO% after deductible <br />Cardiac Rehabilitation 80% after deductible GO% after deductible <br />Emergency use of an Emergency Room` <br />Non-Emmergency use of an Emergency $50 Co a ,then 100% <br />550 Copay ,then 80°io $50 Copay ,then GO% <br />