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e e PPO 300 Plan 44, Option 5 Plan pays for services at PARTICIPATING providers Plan pays for services at NONPARTICIPATING providers Other Medical - Home health care (up to 700 90% after deductible 60% after deductible Services (cont.) visits per calendar year) (2) - Durable medical equipment (2) - Physical, speech and hearing therapy (2), (5) - Ambulance (1) - Private duty nursing (inpatient hospital only) - Hospice (2) - Transplant services (2), (3) 100% after deductible 70% after deductible Mental Health -Inpatient (up to 30 days per 100% after $1 50 copayment per 70% after deductible Services (4) calendar year) (2) day for first five days per admission -Inpatient professional services 90% 60% - Outpatient (up to 30 visits per calendar year) - Individual sessions 100% after a $35 copayment 70% per visit - Group sessions 100% after a $20 copayment 70% per visit Serious Mental -Inpatient (up to 45 days per Covered the same as any Covered the same as any Illness calendar year) (2) other illness other illness - Outpatient (up to 60 visits per calendar year) Chemical -Inpatient (2) Covered the same as any Covered the same as any Dependency - Outpatient other illness other illness Services (lifetime maximum of three separate series of treatments for each insured person) Annual Deductible - Individual $300 $600 (per calendar year) (copayments do not - Family $900 $1,800 apply) Maximum - Individual $2,500 $5,000 Out-Of-Pocket Expense Limit - Family $7,500 $15,000 (per calendar year) (excludes deductibles and copayments) Lifetime Maximum $~,OOO.OOO Benefit * Level One participating physicians include family practitioner, general practitioner, pediatrician or internist and Level Two contains any other participating physician. Please contact Customer Service for details.