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Appendix A Benefits Network �— Non - Network - -� Inpatient Facility Semi - Private Room and Board _ 80% after deductible 60% after deductible Maternity _ 80% after deductible 60% after deductible Skilled Nursing Facility (100 days perbenefit 80% after deductible _ 60% after deductible period) Additional Services _ Ambulance 80% after deductible 60% after deductible Durable Medical Equipment, Prosthetics 80% after deductible 60% after deductibles Home Healthcare _ 80% after deductible Not Covered - --1 Hospice _ _ _ 80% after deductible Not Covered Or an Transplants 80% after deductible 60% after deductible Private Duty Nursing _ _ 80% after deductible 1 60% after deductible Mental Health and Substance Abuse– Mental Health Parit Inpatient Mental Health and Substance Abuse j Services Benefits paid are based on corresponding medical benefit Outpatient Mental Health and Substance Abuse Services Note: Services requiring a copayment are not subject to the single /family deductible. Coinsurance expenses incurred for services by a non - network provider will also apply to the network coinsurance out -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 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 officer of Medical Mutual 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 Mutual'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. 'Maximum family deductible. Member deductible is the same as single deductible. 3 -month carryover applies. ZCopay waived if admitted. 4The copay applies to room charges only. All other covered charges are subject to deductible and coinsurance. Not applied to Coinsurance Out -of- Pocket Maximum SPreventive services include evidence -based services that have a rating of "A" or "B" in the United States Preventive Services Task Force, routine immunizations and other screenings as provided for in the Patient Protection and Affordable Care Act. 4 -1 -05 Opt 2 Plus