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