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2017 Medical Benefits (continued) <br /> PPO 500 Health Fund 1000 Health Fund 1500 <br />MEDICAL BENEFITS Aetna Aetna Aetna <br /> Choice POS II Choice POS II Choice POS II <br /> Current Current Current <br />Basic Lab & Radiology <br /> In-Network Ded./ 20% Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />Major Lab & Radiology (MRI / CT / PET) <br /> In-Network Ded./ 20% Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />In-Patient Hospital <br /> In-Network Ded./ 20% Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />Out-patient Surgery <br /> In Network Ded./ 20% Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />Rehabilitative Therapy PT / OT / ST Maximum 60 visits/year Maximum 60 visits/year Maximum 60 visits/year <br /> In-Network Ded./ 20% Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />In-patient MH / SA <br /> In-Network Ded./ 20% Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />Out-patient MH / SA <br /> In-Network $40 Copay Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />Home Health Care Maximum 120 Visits <br /> In-Network Ded./ 20% Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />Prescriptions <br /> Network Retail Pharmacy $10/$30/$60 $10/$30/$60 $10/$30/$60 <br /> Network Mail Order $20/$60/$120 $20/$60/$120 $20/$60/$120 <br />Specialty RX 20% of the nego. Charge, not to 20% of the nego. Charge, not to 20% of the nego. Charge, not to <br />exceed $100 exceed $100 exceed $100 <br /> Preventive Generics $0 Copay $0 Copay $0 Copay <br /> Step Therapy / Mandatory Generic DAW DAW DAW <br />*In-Network and Out-of-Network *In-Network and Out-of-Network *In-Network and Out-of-Network <br />Deductibles Cross Accumulate Deductibles Cross Accumulate Deductibles Cross Accumulate <br /> <br />4 <br /> <br />