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$50 per visit, waived if admitted to hos- pital.

Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non- PPO: paid at 70%; however, if there was no choice in the hospital used due to an Emergency, the benefit is 90% of Al- lowed Charges.

$20 per visit

Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70%

No Charge for inpatient; $20 per proce- dure for outpatient surgery

Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70%

No Charge

Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70%

$5 per visit for scheduled prenatal care and first post partum visit

Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70%

BENEFITs

Hospital Emergency Room

Physician Office Visits

Surgical Services

X-rays & Lab

Maternity

KaIsER

INdEmNITy

Sterilization Benefits

Co-payment required

Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70%

Adult Physical Exam

$20 per visit

For Participant and Spouse only. The following benefits are subject to plan deductibles and are paid at 90% PPO or 70% Non-PPO: Adult physical limited to $250 in any 12-month period. Out of pocket limits do not apply to charges in excess of the benefit limits. Colonoscopy, Sigmoidoscopy, Mammograms and PSA test for Participants age 50 and over are covered at 90% of contract rates for PPO or 70% Allowed Charge for Non-PPO.

Well Child Care/Routine Physicals for Dependent Children

$5 per visit up to age two, $20 per visit age two and over

Subject to deductible and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70% For children over age 2, benefits are lim- ited to one physical examination in any 12-month period.

Ambulance

No Charge

PREvENTIvE CaRE

Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 90% Allowed Charge

Plan A & R Comparison

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