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In-Network

Out-of-Network

In-Network

Out-of-Network

80%

Not Covered

80%

Not Covered

Childhood Routine Immunization

In-Area Participants

Out-of-Area Participants

Additional Benefits

Coverage for the services listed below are subject to the calendar year deductible of $1,050 individual/$2,100 family and the in-network coinsurance maximum of $2,450 individual/ $4,900 family. These services are not eligible for an

out-of-network review. Benefit

In-Area Participants

Out-of-Area Participants

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-Network

Out-of-Network

In-Network

Out-of-Network

Accidental Injury to Natural Teeth

80%

75%

80%

75%

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 those services listed below are subject to the calendar year deductible of $1,050 individual/$2,100 family and the in-network and out-of-network coinsurance maximums. These services are not eligible for an out-of-

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

Out-of-Area Participants

network review. Benefit

In-Area Participants

15

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