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~~=~-a ~; Benefits ~~ Network ~ ~ Non-iVetu<~ark I n p a t i e n t Facility --- ___-- -- -- __--_ -_--- -f___ r ~i,~li"II-Pri~~~ate Poon~, anti Bcarci ~ d0% after deduciii~le I GD% after deductible - _- ~ I~J;aternit~,~ ~ 80°o after deductii~le I GO% after deductible-_~ Skilled Nursing Facility (i0G days per benefit I d0°io after deductible GO% after deductible period) _ -~ Additioi7al Services -~ Ambulance _ 8U% after deductible _ GU°r~ after deductible Durable IVledical Equipn'ient,_Prostl'ietics - 80`%~ after deductible _ GO% after deductible _ Home h-lealtl'icare 80% afier deductible _ Nof Covered Hospice 80% after deductible Not Covered __ Oraan Transplants 80% after deductible GO% afier deductible _ Private Dut ~ hlursin 80% after deductible 60% after deductible __ Mental Health and Substance Abuse Inpatient IVlental Health and Substance Abuse Services (30 days per admission; Substance Abuse limited to one admission per benefit eriod 50% after deductible blot 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 singlelfamily deductible. Coinsurance expenses incurred for services by anon-network provider will also apply tc 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 ofr'icer of Medical fVlutual 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 Niutual'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. 'IVlaximum family deductible. IVlember deductible is the same as single deductible. 3-month carryover applies. `CopaY waived if admitted. 'Tire copay applies to room charges only. All other cavered charges are subject to deductible and coinsurance. ~Noi applied to Coinsurance Oui-of-Pocket IVtaximum ~.-~-os oir, ~~ raw;