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,...~~..~ __ 1, _. <br /> <br /> <br />~,.-, -~- <br />Cify of f'~ortf~i ~1lrns•i:ed ~h~~~;x~`~~'&~~ <br />~Uj:~~f't~~~d ~'i+vl~~u/~G`~o PIUS Plctf"1 ~~' f'Lr.r.S <br />IJetwork -. ~~ -- Non-rJetwork <br />Benefits <br />P~enefii Period _ <br />Dei~ei-icieni ,'-',gc I_in-tit <br />_ _._---- <br />P_rc-,-E%istinc_ !Cot-iciition VVaitir~c~ Period ___ <br />Blood Pint Deductible <br />Lifetime IVlaxii-r~um <br />Bencr"it Period Deductible -Single/Family <br />Coinsurance <br />Coinsurance Out-of-Pocket IVlaximum <br />(Ercl~dind Deductible) -Single/Family <br />Ph sicianlOfPice Servrces <br />Office Visit (Illness/Injury) <br />Urgent Care Office Visit - <br />\/oluntary Second Surgical Opinion <br />Allen Testin and ~ reatments <br />,'-,II Immunizations (including Routine) <br />Preventative Services <br />Office \/isit/Routine Physical F>;am <br />(One exam per b°nefit period) <br />Well Child Care Services including E~.am and <br />Immunisations (to age nine) _ _ <br />\Nell Child Care Laboratory Tests (to age 9~ <br />Routine Mammo ram one er benefit period <br />Routine Pap Test one er benefit eriod <br />Routine F_i:G, Chest X-ray, Complete Blood <br />Count, Comprehensive 1Vietabolic Panel, <br />Urinalysis <br />Out afiient Services <br />Surgical Services <br />Diagnostic Services <br />Physical/Occupational Therapy -Facility and <br />Professional (10 visits then Med_ Review. <br />Chiropractic Therapy -Processional Only <br />Unlimitel <br />Speech Therapy - Faciiity and Professional <br />_('I 0 visJt~ thei ~ Flied P.evi~w <br />Cardiac Rehabilitation <br />Emergency use of an Emergence P.oor~n~_ <br />I~lon-Emergency use of an Emergency <br />ROOnI`'~' <br />January 1`''tl-u-oucth December ~'1 <br />19 Dependent / 25 Student <br />_ Ren~ioval ul:~or~ C;irlh Date _ <br />No ~ object 1:o Pre-E>: <br />--- -- 0 pir~t~ ~-- <br />J~2,JOO ,ODO <br />_ 5;200 I $400 _ x;400 / ~;cSUO <br />80`% GO% <br />$;1,000 / 5;2, UOp 5;2, 000 / $4 ; 000 <br />80°~~ after deductible 60% after deductible <br />80% after deductible ~ 0% after deductible <br />80% after deductible GO% after deductible <br />80% after deductible ~ GO% after deductible <br />80% after deductible ~ IJot Covered <br />80% after deductible i Not Covered <br />80% after deductible I Not Covered <br />100 %. <br />I OD <br />10D °10 <br />10D <br />80% after deductible GO% after deductible <br />1 OD <br />80% after deductible GD% after deductible <br />80`%-ductible GO`% after deductible <br />80% after deductible GO°I° after deductible <br />80"/° after deductible GO°!° after deductible <br />5;5U Copay ,then 100°~0 <br />5:50 Copay ,then 80% 5;50 Copay ,then GO°k~ <br />