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BENEFITS PPO Covera e NON-PPO <br /> g Coverage <br /> Other Covered Services: Prescription drugs, blood and blood <br /> components; leg, arm, back, and neck braces; services of a private � <br /> duty nursing ($1,000" per month maximum); ambulance services; <br /> allergy shots; oxygen and its administration; surgical dressings, $�o�o <br /> casts and splints; durable medical equipment; prosthetic devices; <br /> services of a registered professional physical therapist, <br /> occupational therapy and speech therapy ($1,000* maximum per <br /> calendar year). <br /> Temporomandibular Joint Dysfunction & Related Disorders $1,000* <br /> Lifetime Maximum: <br /> BASiC PROVISIONS <br /> Medical Services Advisory: Notification required prior to all elective admissions. Emergency and <br /> Obstetric Admission Notification required within 2 working days of admittance. If employee elects not to <br /> notify MSA Advisor or follow advice given, hospital benefits reduced by$500". <br /> Pre-Existing Conditions Waiting Period: 365 day waiting period. <br /> Dependent Eligibility: To age 23. <br /> Coordination of Benefits: This program coordinates benefits with other group plans. <br /> ` Co-payments do not apply to any out-of-pocket expense limitation. Coinsurance amounts,except as otherwise noted, apply to <br /> the PPO Out-of-Pocket Expense Limitation. <br /> "" Deductible does not apply. <br /> 40 <br />