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Payment Levels Differing from General Program Payment Provisions (cont'dj* <br /> Chiropractic Services Calendar Year Maximum: $ per calendar year($500 or$1,000) <br /> -(paid at�Program Payment Level; coinsurance not applicable to OPX) <br /> TMJ: �Yes ❑ No <br /> If yes; ❑$2,500 lifetime max(std) ❑$ per lifetime max($1,000, $2,000 or$3,000) <br /> ❑$ per ca/endar year max ❑ No separate TMJ maximum <br /> (paid at Program Payment Level; coinsurance not applicable to OPX) <br /> Emergency Care and Accident Care Benefits* <br />, Emergency Accident Care/Emer ency Medical Care initial visit only : <br /> 9 ( ) <br /> Payment Level: % <br /> Program Deductible applies to Emergency AccidenUMedical Care(Hospital & Physician): ❑Yes O No <br /> Separate Accident Care Benefit(includes initial visit): ❑ Yes ❑ No <br /> If yes, paid at 100%up to a <br /> maximum per accident of: $ ;then paid at % <br /> Program Deductib�e appiies to Separate Accident Care(Hospital&Physician): ❑ Yes ❑ No <br /> Suppiemental Accident Care Benefit(excludes initial visit): ❑Yes ❑ No <br /> If yes, paid at 100% up to a <br /> maximum per accident of: $ ;then paid at % <br /> Program Deductible applies to Supplemental Accident Care(Hospital&Physician): ❑ Yes 0 No <br /> Mental Health and Substance Abuse Rehabilitation T�eatment Benefits* <br /> Inpatient Services: (coinsurance and/or deductible not applicable to OPX) <br /> Hospital Payment Level: %; ❑ for first days, then 50%thereafter <br /> Physician Payment Level: % <br /> Calendar Year Maximum Payable: $ ($10,000 or$25,000) <br /> Deductible per Admission: ❑Yes ❑ No If yes, Deductible Amount: $ <br /> Outpatient Services: (coinsurance and/or deductible not applicable to OPX) <br /> Payment Level: % (50%std) <br /> Maximum Payable per Visit: $ ($20-$60) Maximum Number of Visits: per Calendar Year <br /> Calendar Year Maximum: $ ($250-$2,500) <br /> Inpatient&Outpatient Combined Lifetime Maximum: $ ($25,000 or$50,000) ��, <br /> Other Provisions* ' <br /> Additional Surgical Opinion 100%: ❑ Yes ❑ No I'� <br /> Mandatory Additional Surgical Opinion Program: ❑ Yes ❑ No �I <br /> (applies to Hospital and Physician) If yes, benetit reduction: �, <br /> Mandatory Outpatient Surgery Program: ❑Yes ❑ No I! <br /> (applies to Hospital and Physician) If yes, benefit reduction: !I <br /> An Independent licensee of the Blue Cross and Blue Shield Association I' <br /> OB 3172 Rev.7/97 'Any variations other than those specified require Start-Up Committee approval. page 2 I <br />