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Appendix A <br />City of North Olmsted <br />MEDICAL <br />S <br />MUTUAL_ SuperMed Plus Plan uperMed <br />Effective 2015 Plus` <br />Benefits <br />Benefit Period <br />F Networ F Non- Network <br />January 1st through December 31S <br />Dependent Age <br />Older Aged Child <br />26 <br />28 <br />Removal upon End of Month <br />Pre - Existing Condition Waiting Period <br />No Sub ect to Pre-Ex <br />Blood Pint Deductible _ <br />0 pints <br />Overall Annual Benefit Period Maximum <br />unlimited <br />Benefit Period Deductible — Sin le/Family' <br />$200/$400 <br />$400 /$800 <br />Coinsurance _ <br />80% <br />60% <br />Coinsurance Out -of- Pocket Maximum <br />-(Excluding Deductible) — Single /Famil <br />$1,000 / $2,000 <br />$2,000 / $4,000 <br />Physician/Office Services _ <br />Office Visit (Illness/Injury) <br />80% after deductible <br />60% after deductible <br />Ur ent Care Office Visit <br />80% after deductible <br />60% after deductible <br />Allergy Testing and Treatments <br />All Immunizations (including Routine <br />80% after deductible <br />80% after deductible <br />60% after deductible <br />Not Covered <br />Preventive Services <br />Preventive Services, in accordance with state <br />I and federal law' <br />Office Visit /Routine Physical Exam <br />—ROne exam per benefit period) <br />100% <br />100% <br />_ <br />Not Covered <br />Not Covered <br />outine office visit in conjunction with a PAP <br />Not Covered <br />Well Child Care Services including Exam, <br />Routine Vision, Routine Hearing Exams, Well <br />Child Immunizations and Laboratory Tests <br />(to age 21 _ <br />_100% <br />100% <br />Not Covered <br />Routine Mammogram one per benefit enod <br />100% <br />Routine Pap Test one per benefit period <br />100% <br />Routine PSA (one per benefit period <br />100% <br />All Routine Labs, Tests and X -ra s _ <br />_ <br />100% <br />Outpatient Services _ <br />Surgical Services _ <br />80% after deductible 60% after deductible <br />Diagnostic Services _ <br />100% <br />Physical /Occupational Therapy - Facility and <br />Professional (10 visits then Med Review <br />80% after deductible <br />_ <br />60% after deductible <br />Chiropractic Therapy— Professional Only <br />(Unlimited)_ <br />80% after deductible <br />60% after deductible <br />Speech Therapy — Facility and Professional <br />10 visits then Med Review)_ <br />80% after deductible <br />60% after deductible <br />Cardiac Rehabilitation <br />80% after deductible <br />60% after deductible <br />Emergency use of an Emergency Roo <br />$50 Co pa , then 100% <br />Non - Emergency use of an Emergency <br />Room2,3 <br />$50 Copay, , then 80% <br />$50 Copay, , then 60% <br />