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COVERED SERVICES NETWORK PROVIDERS NON-NETWORK <br /> PROVIDERS <br /> Physician Services <br /> In atient visits 90% after deductible 80% of the maximum allowance <br /> Office visits 90% after deductible 80% of the maximum allowance <br /> Sur e 90% after deductible 80%of the maximum allowance <br /> Home Health Care 90% after deductible 80%of the maximum allowance <br /> Outpatient Private Duty 90�Io after deductible 70%after deductible <br /> Nursing �1,000 er month maximum $1.000 r month maximum <br /> Hospice Care 90% after deductible 70%after deductible <br /> Ambulance Service 90% after deductible 90%after deductible <br /> Jaw JoinUTMJ 90% after deductible 80%after deductible <br /> $1,000 Lifetime maximum $1,000 Lifetime maximum <br /> Wig After Chemotherapy 90�/o after deductible 80%after deductible <br /> one er Lifetime maximum one r Lifetime maximum <br /> Occupational Therapy 90% after deductible 80%after deductible <br /> (Maintenance not covered) $1,000 Calendar Year maximum $1,000 Calendar Year maximum <br /> Speech Therapy 90% after deductible 80%after deductible <br /> (Maintenance not covered) $1,000 Calendar Year maximum $1,000 Calendar Year maximum <br /> Physical Therapy 90% after deductible 80%after deductible <br /> (Maintenance not covered) $1,000 Calendar Year maximum $1,000 Calendar Year maximum <br /> Durable Medical Equipment 90%o after deductible 80%after deductible <br /> Prosthetics 90% after deductible 80%after deductible <br /> Orthotics 90% after deductible 80%after deductible <br /> (Flat foot not covered) <br /> Spinal Manipulation 90% afrer deductible 90°Io after deductible <br /> Chiropractic $1,000 Calendar Year maximum $1,000 Calendar Year maximum <br /> Mental Disorders <br /> Inpatient 90% after deductible 70°lo after deductible <br /> 200 days Lifetime maximum 200 days Lifetime maximum <br /> combined with Substance Abuse combined with Substance Abuse <br /> Outpatient 90% after deductible 70%afrer deductible <br /> 20 visits Calendar Year maximum 20 visits Calendar Year maximum <br /> combined with Substance Abuse combined with Substance Abuse <br /> Substance Abuse <br /> Inpatient 90% after deductible 70% after deductible <br /> 200 days Lifetime maximum 200 days Lifetime maximum <br /> combined with Mental Disorders combined with Mental Disorders <br /> Outpatient 90% after deductible 70%after deductible <br /> 20 visits Calendar Year maximum 20 visits Calendar Year maximum <br /> combined with Mental Disorders combined with Mental Disorders <br /> Preventive Care <br /> Pap smear, mammogram, 90%o after deductible 80%after deductible <br /> prostate screening and digital <br /> rectal and colon rectal cancer <br /> screenin s <br /> Frequency limits for mammogram <br /> Ages 35 through 39 . . . . . . . . . . . . single Baseline mammogram ' <br /> Ages 40 through 49 . . . . . . . . . . . . every two years � <br /> A es 50 and over. . . . . . . . . . . . . . annuall <br /> Routine Newborn 90% after deductible 80%after deductible <br /> Nurserv/Ph sician Care <br /> 13 <br />