Plan Feature	Network Benefit	Out-of-Network Benefit
LIFETIME MAXIMUM Except for Chemical Dependency and/or Substance Abuse Conditions	$1,000,000	$1,000,000
CALENDAR YR. DEDUCTIBLE	Single = $250 / Family = $750	Single = $750 / Family = $2,250
Applicable to Calendar Year Deductible: Outpatient Hospital Expenses Maternity (prenatal/outpatient services) Diagnostic X-Rays & Labs Convalescent Facility Expenses Private Duty Nursing Chemical Dependency/Substance Abuse Disorders Chiropractic Care Fertility Testing Short-Term Rehab Ambulance Anesthetics DME & Oxygen Prosthetics Hearing Aids Surgery Partial Hospitalization Inpatient Hospital Services Speech Therapy Home Health Hospice Allergy Testing
COINSURANCE LIMIT Maximum Out of Pocket	Single = $1,500 / Family = $3,000	Single = $3,000 / Family = $6,000
PHYSICIAN OFFICE VISITS PRIMARY CARE Excludes X-Ray & Labs Excludes Chemical Dependency and/or Substance Abuse	$25 Copay	60% Coinsurance after Calendar Year Deductible
PHYSICIAN OFFICE VISIT SPECIALIST Excludes X-Ray and Lab Services Excludes Chemical Dependency and/or Substance Abuse	$25 Copay	60% Coinsurance after Calendar Year Deductible
ROUTINE WELL CHILD EXAM & IMMUNIZATION Up to age 6 Maximum $500/Child	$25 Copay	60% Coinsurance after Calendar Year Deductible
ROUTINE PHYSICAL EXAMS Coverage limited to $300/member/year Applicable to Employees and Covered Dependents	Applicable Copay -- $25 Primary Care $25 Specialist	NO COVERAGE
DIAGNOSTIC X-RAYS, LABORATORY, ALLERGY TESTING and ALLERGY MEDICATIONS - Unrelated to Office Visit	80% Coinsurance after Calendar Year Deductible	60% Coinsurance after Calendar Year Deductible
HOSPITAL EXPENSES  ** Conditions OTHER than Mental, Nervous, or Substance Abuse Inpatient Outpatient	80% Coinsurance after Inpatient Deductible 80% Coinsurance after Calendar Year Deductible	60% Coinsurance after Inpatient Deductible 60% Coinsurance after Calendar Year Deductible
HOSPITAL EMERGENCY ROOM Waived if admitted within 24 hours	$75 Copay	$150 Copay $75 if out of town on business
MATERNITY Prenatal - Outpatient Inpatient	80% Coinsurance after Calendar Year Deductible 80% Coinsurance after Calendar Year Deductible	60% Coinsurance after Calendar Year Deductible 60% Coinsurance after Calendar Year Deductible
SURGERY	80% Coinsurance after Calendar Year Deductible	60% Coinsurance after Calendar Year Deductible
SPEECH THERAPY Lifetime Maximum = $15,000 Services must be provided by qualified speech therapist for medically determinable conditions	80% Coinsurance after Calendar Year Deductible	60% Coinsurance after Calendar Year Deductible
CONVALESCENT FACILITY EXPENSES 3 days of prior hospitalization required. Must begin within 14 days following end of confinement Maximum 60 days/calendar year	80% Coinsurance after Calendar Year Deductible	60% Coinsurance after Calendar Year Deductible
HOME HEALTH CARE Prior hospital confinement NOT required Nurses Aide Visits 4 Hours = 1 Visit Maximum 100 Visits/Calendar Year	80% Coinsurance after Calendar Year Deductible	60% Coinsurance after Calendar Year Deductible
HOSPICE EXPENSES	80% Coinsurance after Calendar Year Deductible	80% Coinsurance after Calendar Year Deductible
CHIROPRACTIC CARE Maximum $500/Calendar Year	80% Coinsurance after Calendar Year Deductible	80% Coinsurance after Calendar Year Deductible
FERTILITY TESTING Minimum 12 months coverage under this Plan Family Maximum = $25,000	80% Coinsurance after Calendar Year Deductible	60% Coinsurance after Calendar Year Deductible
HEARING AIDS Initial device{s} covered only if necessary to restore hearing lost due to accidental injury while covered under the Plan	80% Coinsurance after Calendar Year Deductible	80% Coinsurance after Calendar Year Deductible
PRIVATE DUTY NURSING (RN Only) Maximum 70 shifts/calendar year. 1 shift = 8 hours of Private Duty Nursing by RN only	80% Coinsurance after Calendar Year Deductible	60% Coinsurance after Calendar Year Deductible
AMBULANCE	80% Coinsurance after Calendar Year Deductible	80% Coinsurance after Calendar Year Deductible
ANESTHETICS	80% Coinsurance after Calendar Year Deductible	80% Coinsurance after Calendar Year Deductible
DURABLE MEDICAL EQUIPMENT & OXYGEN Coverage for rental up to purchase price	80% Coinsurance after Calendar Year Deductible	80% Coinsurance after Calendar Year Deductible
SHORT-TERM REHABILITATION Maximum 60 days/calendar year	80% Coinsurance after Calendar Year Deductible	80% Coinsurance after Calendar Year Deductible
PRECERTIFICATION - INPATIENT  ** Conditions OTHER than Mental, Nervous or Substance Abuse Precertification requested & approved Precertification requested & denied (stay not necessary) Precertification not requested	No Penalty 80% Coinsurance after Calendar Year Deductible $500 Penalty + 80% Coinsurance after Calendar Year Deductible $500 Penalty + 80% Coinsurance after Calendar Year Deductible	No Penalty 60% Coinsurance after Calendar Year Deductible $500 Penalty + 60% Coinsurance after Calendar Year Deductible $500 Penalty + 60% Coinsurance after Calendar Year Deductible
PRECERTIFICATION - OUTPATIENT Required for all Designated Procedures  ** Conditions OTHER than Mental, Nervous or Substance Abuse Precertification requested & approved Precertification requested & procedure deemed appropriate Precertification not requested & procedure deemed unnecessary	80% Coinsurance after Calendar Year Deductible 70% Coinsurance after Calendar Year Deductible NO COVERAGE	60% Coinsurance after Calendar Year Deductible 60% Coinsurance after Calendar Year Deductible NO COVERAGE

TREATMENT FOR MENTAL or NERVOUS CONDITIONS
OFFICE VISITS Treatment by MD (including Psychiatrist) or Psychologist (PhD) Maximum 25 Visits per calendar year	$25 Copay	25% Coinsurance after Calendar Year Deductible
PRECERTIFICATION - INPATIENT  ** Days must be precertified and under case management  ** Maximum 10 days per calendar year Precertification requested & approved Precertification requested & denied (stay not necessary) Precertification not requested  ** PARTIAL HOSPITALIZATION Outpatient Program Conversion to Inpatient Day Limit	No Penalty 80% Coinsurance after Calendar Year Deductible $500 Penalty + 80% Coinsurance after Calendar Year Deductible $500 Penalty + 80% Coinsurance after Calendar Year Deductible 80% Coinsurance after Calendar Year Deductible 2 for 1	No Penalty 25% Coinsurance after Calendar Year Deductible $500 Penalty + 25% Coinsurance after Calendar Year Deductible $500 Penalty + 25% Coinsurance after Calendar Year Deductible 25% Coinsurance after Calendar Year Deductible 1 for 1

TREATMENT FOR CHEMICAL DEPENDENCY or SUBSTANCE ABUSE
LIFETIME MAXIMUM - Chemical Dependency or Substance Abuse	$10,000 / Individual $20,000 / Family	$10,000 / Individual $20,000 / Family
OFFICE VISITS Treatment by MD (including Psychiatrist) or Psychologist (PhD) Maximum 25 Visits per calendar year	$25 Copay	25% Coinsurance after Calendar Year Deductible
PRECERTIFICATION - INPATIENT  ** Days must be precertified and under case management  ** Maximum 10 days per calendar year Precertification requested & approved Precertification requested & denied (stay not necessary) Precertification not requested  ** PARTIAL HOSPITALIZATION Intensive Outpatient Outpatient Hospital & Inpatient Physician Intensive Outpatient Conversion to Inpatient Day Limit	No Penalty 80% Coinsurance after Calendar Year Deductible $500 Penalty + 80% Coinsurance after Calendar Year Deductible $500 Penalty + 80% Coinsurance after Calendar Year Deductible 80% Coinsurance after Calendar Year Deductible 50% Coinsurance after Calendar Year Deductible 3 for 1	No Penalty 25% Coinsurance after Calendar Year Deductible $500 Penalty + 25% Coinsurance after Calendar Year Deductible $500 Penalty + 25% Coinsurance after Calendar Year Deductible 25% Coinsurance after Calendar Year Deductible 25% Coinsurance after Calendar Year Deductible 2 for 1