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Coinsurance expenses Incurred for services by anon-network provider will also apply to the network coinsurance ouf-of-pocket limits, Coinsurance expenses incurred for services by a network provider will 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 IVlutual's medical and administrative policies and procedures. This document is only a partial fisting of benefits. This is not a contract of insurance. I'Jo person otherth~an an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed Mere, The contract or certir'icate will contain the complete listing of covered services, In certain instances, Medical IVlutual's payment may not equal the percentage listed abrn+e. 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. hximum family deductible. IVlember deductible is tide same as single deductible. 3-inonti~i carryover applies. `Copal' waived if admitted. •{The ropay applies to room charges only. P,II other covered charges are subiecl io deductible and coinsurance, 'Not applied to Coinsurance Dui-of-Pocket Maximus-~ ., '. •OS 6p', 2 Pius Note: Services requiring a copyament are not subject to the singlelfamily deductible.