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r-�otess�ona� Prov�der f3enefits* ' <br /> . PPO Non-PPO I', <br /> G�neral•Payment Level: % qo '� <br /> Copayment per office visit: ❑ Yes ❑ No If yes, $ ❑Yes ❑ No If yes, $ ' <br /> Program Deductible Applies: [� Yes ❑ No ❑Yes ❑ No � <br /> utpatient urgical ervices: <br /> Payment LeveL• % ��� ' <br /> Program Deductible Applies: L� Yes 0 No ❑ Yes ❑ No � <br /> utpaUent iagnosUc ervices: � ' <br /> Payment Level: % ��o ' <br /> Program Deductible Applies: ❑ Yes ❑ No O Yes ❑ No � <br /> Chiropractic Services Calendar Year Maximum: ❑ Yes ❑ No If yes, $ ($1,000 std, PPO and Non-PPO combined) <br /> Emergency Care and Accident Care Benefits* I <br /> PPO Non-PPO <br /> Emergency Accident Care: <br /> (initial visit ohly) <br /> Hospital Payment Level: °io ��o <br /> Physician Payment Level: % % ' <br /> Emergency Room Copayment: � Yes ❑ No If yes, $ ❑ Yes ❑ No !f yes, $ <br /> mergency oom opayment app ies to npatient e ucti e i a mitte : es o <br /> rogram e ucti e app ies to mergency cci ent are osp�ta ysician : es o <br /> mergency e ica are: <br /> (initial visit only) <br /> Hospital Payment Level: % % <br /> Physician Payment Level: % % <br /> Emergency Room Copayment: ❑ Yes ❑ No If yes, $ � Yes ❑ No lf yes, $ <br /> mergency oom opayment app ies to npatient e ucti e i a mitte : es o <br /> Program eductible applies to mergency Medical are ospitai& Physician): ❑ es ❑ No <br /> eparate Accident are Bene rt <br /> (includes initial visit): ❑ Yes � No ❑ Yes ❑ No <br /> 100%up to a maximum per accident of: $ ;then paid at °/a $ ;then paid at % <br /> rogram e ucti e app ies to eparate cci ent are Hospital& Physician : es o <br /> upp emental Acci ent are Bene �t <br /> (excludes initial visit): ❑ Yes ❑ No � Yes� No <br /> 100%up to a maximum per accident of: $ ;then paid at % $ ;then paid at % <br /> rogram e ucti e app ies to upp ementa cci ent are(Hospital& Physician): ❑ es o <br /> Mental Health and Substance Abuse Rehabilitation Treatment Benefits* <br /> Inpatient Services PPO Non-PPO <br /> (coinsurance and/or deducubles not applicable to OPX): <br /> Hospital Payment Level: %; ❑for first _days, %; ❑ for first days, <br /> then 50%thereafter then 50%thereafter <br /> Physician Payment Level: °% % <br /> Maximum Payable per Visit: $ $ <br /> Maximum Number of <br /> Visits per Calendar Year <br /> (combined PPO/Non-PPO): — <br /> Prcgram Deductible Applies: ❑ Yes ❑ No 0 Yes ❑ No <br /> Inpatient Hospital Ceductible ❑ Yes ❑ No If es, $ <br /> per Admission: Y ❑ Yes ❑ No rf yes, $ <br /> IP Hosp. Ded. applies to OPX: ❑ Yes ❑ No ❑ Yes ❑ No <br /> Inpatient Calendar Year Maximum (combined PPO/Non-PPO): $ <br /> An Independent Licensee of the Blue Cross and Blue Shield Association <br /> oB 31 ss Rev.7/s7 *Any variations other than those specified require Start-Up Committee Approval page 2 <br />� <br />