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Additional Benefits

Coverage for the services listed below is subject to the in-network calendar year medical deductibles and the individual medical coinsurance maximum of $2,000. These services are not eligible for an out-of-network review.

Anesthesia

80%

75%

80%

75%

Podiatry Services

80%

75%

80%

75%

Ambulance

80%

75%

80%

75%

Medical Supplies

80%

75%

80%

75%

Prosthetic and Orthotic

80%

75%

80%

75%

Procedures and Devices TMJ

80%

75%

80%

75%

In-Area

Participants

In-Network 80%

Out-of-Network 75%

Out-of-Area Participants

In-Network

Out-of-Network

80%

75%

Benefit

Accidental Injury to Natural Teeth

In-Network

Out-of-Network

In-Network

Out-of-Network

80% 50% 50%

75% 50% 50%

80% 50% 50%

75% 50% 50%

80% 50% 80%

75% 50% 75%

80% 50% 80%

75% 50% 75%

Mental Health/Substance Abuse Benefits

Coverage for the services listed below is subject to the in-network calendar year medical deductibles. These services are not eligible for an out-of-network review. Coinsurance amounts for substance abuse and mental health benefits

Substance Abuse Inpatient Outpatient Intensified Outpatient Program Mental Health Inpatient Outpatient Day Treatment/ Partial Hospitalization

will not apply toward satisfying the coinsurance maximum.

Benefit

In-Area Participants

Out-of-Area Participants

10

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