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EXHIBIT H <br /> � Preferred Provider O tion PP <br /> p � ) <br /> Schedule of Benefits In-Nefinrork Out of Network <br /> Hospital Benefit - InpatienbOutpatient 80% of eligible charge 60% of eligible charge <br /> 80% of scheduled 60% of scheduled <br /> Medical/surgical care (Physicians) maximum allowance (max. maximum allowance (max. <br /> allow. allow. <br /> Emergency care 100% of eligible charge - 100% of Usual & <br /> no deductible Customa - no deductible <br /> Inpatient mental 80% of eligible charge 60% of eligible charge <br /> Outpatient mental 80% of max. allow. 60% of max. allow. <br /> 20 visits er ear 20 visits er ear <br /> In and outpatient mental combined limit 200 days lifetime max. 200 days lifetime max. <br /> Chiropractic services 80% of max. allow. 60% of max. Allow. <br /> $1,000/calendar ear max. $1,000/calendar ear max <br /> Prescription medicines Co-pays Generi $10 <br /> (Not subject to annual deductible; not Formul ry $20 <br /> � applied to maximum out-of-pocket) Non-form la $50 <br /> Private duty nursing $1,000 per onth max. <br /> Physical therapy $1,000 per ear max. <br /> Occupational therapy $1,000 per ear max. <br /> Speech therapy $1,000 per ear max. <br /> TMJ/related disorders $1,000 life ime max. <br /> Pre-certification $500 reduction in benefits fo failure to notify National <br /> Health Service when receivin in atient services. <br /> Lifetime maximum (including major organ $2,00 ,000 <br /> transplants) <br /> Major Plan Features Tier 1 Tie 2 Tier 3 <br /> Deductible <br /> (individual) In Network $250 $5 0 $750 <br /> (individual) Out of Network $500 $1, 00 $1,500 <br /> Family—3 individual deductibles <br /> Out-of-Pocket Limit <br /> (individual) In Network $1,500 $2, 00 $2,500 <br /> (individual) Out of Network $5,000 $6, 00 $7,500 <br /> Family—3 individual limits <br /> Wellness Benefit(individual) $250 $2 0 $250 <br /> Health Credits per individual $25 each $50 ach $75 each <br /> (max of 4 per individual) <br /> Note. The above chart represents only a summary of plan benefits and related information, an is provided for illustrative purposes <br /> only. It is not intended as a substitute for the plan document. For detailed information on plan enefits. conditions, limitations, and <br /> exclusions,please refer to the plan document. <br /> 41 <br />