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Hospital – In-patient

80%

60%

80%

75%

Hospital – Out-patient

80%

60%

80%

75%

Emergency Room

80%

60%

80%

75%

X-Rays, Laboratory

80%

60%

80%

75%

Adult Wellness/Preventive

100%

Not Covered

100%

Not Covered

Lifetime Maximum Benefits

In-Network

Out-of-Network In-Network $1,000,000

Out-of-Network

Individual Calendar Year Medical Deductible

$500

$1 000

,

$500

$1,000

Family Calendar Year Medical Deductible

$1,000

$2,000

$1,000

$2,000

Individual Medical Coinsurance Maximum

$2,000

$3,000

$2,000

$3,000

Home Infusion Therapy

80%

60%

80%

75%

Nurse Practitioner

80%

60%

80%

75%

Occupational Therapy

80%

60%

80%

75%

Optometric Services

80%

60%

80%

75%

Organ Transplants

80%

60%

80%

75%

Physical Therapy

80%

60%

80%

75%

Private Duty and Home

80%

60%

80%

75%

Summary of Select Coverage Medical Benefits

This is only a summary of the medical benefits under Select Coverage. It does not provide all details and provisions of the Plan. Some limitations and exclusions apply and can be found within this Plan Document.

In-Area Participants

Out-of-Area Participants

Chiropractic Services

80%

60%

80%

75%

Durable Medical

80%

60%

80%

75%

Well-Newborn Nursery Care

100%

High Option for Children Not Covered

100%

Not Covered

Well-Child Physician Office Visits

100%

Not Covered

100%

Not Covered

Specified Routine Tests

100%

Not Covered

100%

Not Covered

Childhood Routine Immunization

80%

Not Covered

80%

Not Covered

All benefits are subject Services section. Physician Services

80%

75%

9

100%

90%

100%

90%

80%

60%

80%

75%

100%

Not Covered

100%

Not Covered

80%

60%

80%

75%

80%

60%

80%

75%

to the medical deductibles unless otherwise noted

in the Covered

80%

60%

80%

75%

60%

Services

Maternity – Attending Physician

Maternity – Hospital; Other Services

Well-Child Care (Birth to 2 Years of Age)

Ambulatory Surgical Facility

Cardiac Rehabilitation (outpatient)

Equipment

Health Nursing Services

Speech Therapy

80%

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