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EXHIBIT G <br /> PPO PLUS <br /> Note: This provides only the highlights of the program. Specific details are contained in the ma ter policy issued to the group. <br /> BENEFITS PPO overa e NON-PPO <br />, g Coverage <br /> Lifetime Comprehensive Major Medical Coverage $2,000,000 <br /> Deductible per individual, per calendar year $100 $200 <br /> (family deductible: a maximum of three individual deductibles) <br /> Transplant Coverage: Heart, heart/lung and liver transplants in <br /> approved facilities paid as any other condition with prior approval by <br /> MSA Advisor. <br /> Out-of-pocket Expense Limitation: The amount of money <br /> individual pays toward covered hospital and medical expenses $1,000 $5,000 <br /> during any one calendar year, including the deductible. <br /> Inpatient Hospital Services: Room allowance based on the <br /> Hospital's most common semi-private room rate. Pre-Admission <br /> testing, Skilted Nursing Facility and Coordinated Home Care are <br /> paid on the same basis. Benefits for an Inpatient Hospital 0°/a 60% <br /> Admission that resulted from Emergency Accident or Emergency <br /> � Medical Care will be provided at 80% of the Hospital's Eligible <br /> Charge regardless of whether care is received in a Participating or <br /> , Non-Participating hospital. <br /> �i Outpatient Surgery & Diagnostic Tests: (Hospital) 0% 60% <br /> Outpatient Emergency: Emergency Medical and Emergency <br /> Accident (first visit). If an inpatient admission occurs thereafter, the 10 %*" 100%`" <br /> MSA must be contacted within two business days. <br /> Outpatient Hospital Services: Including Radiation & 0% 60% <br /> Chemotherapy. <br /> Inpatient Mental and Substance Abuse: Maximum lifetime g %* 60%" <br /> benefits of$50,000 for Inpatient and Outpatient services. <br /> Outpatient Mental and Substance Abuse: Maximum lifetime <br /> benefits of $50,000 for Inpatient and Outpatient services. 5 %" 50%" <br /> Outpatient Care limited to $1,300 per calendar year. <br /> Medical Surgical Care: For inpatient or intensive care, medical <br /> and surgical care; physician office visits; consultation; anesthetics. <br /> Payments are based on the Schedule of Maximum Allowances. <br /> PPO Providers have agreed to accept the Schedule of Maximum <br /> Allowances as payment in full for covered services, excluding your 8 % 60% <br /> deductible and any Coinsurance. <br /> Non-PPO providers do not accept the Schedule of Maximum <br /> Allowances as payment in full. You will be liable for any differences <br /> between the physician's charge and our payment. <br /> Chiropractic Services: Care limited to $1,000 per calendar year 8 %" 60%" <br /> 39 <br />