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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 per benefit 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 deductible • Home Healthcare 80% after deductible Not Covered Hospice 80% after deductible Not Covered Organ Transplants 80% after deductible 60% after deductible Private Duty Nursing 80% after deductible 60% after deductible Mental Health and Substance Abuse— Mental Health Parity Inpatient Mental Health and Substance Abuse 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. 2Copay waived if admitted. 3The copay applies to room charges only.All other covered charges are subject to deductible and coinsurance. 4Not applied to Coinsurance Out-of-Pocket Maximum 5Preventive 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