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e e CoverageFirst 1000 Plan pays for services from plan pays for services from Plan 35, Option 84 PARTICIPATING providers NONPARTICIPATING providers Hospital Services · Inpatient care (semiprivate room 100% after $100 co payment 70% after deductible and board, nursing care, leU) (2) per day for first five days per admission, and after deductible · Outpatient surgery - facility (2) 100% after $ 50 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 80% after deductible 60% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $100 copayment 70% after deductible per visit after deductible (copayment is waived if admitted) Prescription Drugs · Rx4 See attached rider, if applicable Other Medical · Skilled nursing facility (up to 80% after deductible 60% after deductible Services 60 days per calendar year) · Home health care (up to 100 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 $100 copayment 70% after deductible Services (4) calendar year) (2) per day for first five days per admission · Inpatient professional services 80% 60% · Outpatient (up to 30 visits per calendar year) -Individual sessions 100% after a $20 copayment 70% per visit - Group sessions 100% after a $1 0 copayment 70% per visit Serious · Inpatient (up to 45 days per Covered the same as any Covered the same as any Mental Illness calendar year) (2) other illness other illness · Outpatient (up to 60 visits per calendar year) Chemical Dependency · Inpatient (2) Covered the same as any Covered the same as any (lifetime maximum of · Outpatient other illness other illness three separate series of treatments for each insured person) * 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.