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ti <br />'S `IAJFti <br />I <br />i <br />Substance Abuse <br />Prex <br />Skilled Nursing Facility <br />Preventive Health Services(Adult) <br />Preventive Health Senvices(Chlid) <br />Physical Therapy <br />11 <br />K <br />Out of Pocket <br />Per Admission Deductible <br />Office services <br />Oral Surgery <br />Mammograms <br />Mental/Nervous <br />Hospice <br />Independent Clinical Laboratories _J <br />Elective Abortions <br />Emergency Room <br />Dependent Daughter Maternity <br />Durable Medical Equipment <br />Deductible <br />Deducible Carryover_ <br />Contraceptive Injections <br />Coeay <br />Blood and Blood Plasma <br />Coinsurance <br />Annual Restoration of Benefits <br />Birthing Centers <br />1, <br />Y <br />covered under drug card <br />0 <br />No limitations(Indudes Cardiac, <br />Pulmonary, Occupational, and Speech) <br />BlueScript $8416/ Oral Contraceptives <br />Not Covered / Sexual Dysfunction <br />Covered/ Mall Order 90 Days 1x <br />N <br />li <br />$15 copay - <br />Covered <br />C <br />'N N <br />88 <br />; <br />N/A <br />S2500 LTM <br />$5000 LTM <br />i <br />Not Covered <br />N/A <br />Np <br />v <br />1,„ <br />Not Covered <br />S15(ofice visit) <br />Covered <br />80%/60% 80%0°n -eligibles) <br />Subject to Ded. and Coins. <br />80% <br />First $500 paid at 100% <br />Covered <br />y <br />.s <br />� . <br />.,_ <br />'Q <br />Isubject to deductible and co insurance I <br />g <br />Ofzyi <br />g <br />N <br />$200 CYM (par all adults ) <br />Not Subject to Deductible <br />$2500 PCY(Indudes Spinal <br />Manipulations. PhysicaUMassage <br />Therapy. Occupational, Speech, and <br />Cardiac Therapy. <br />BlueScript $5/$15430/lndudes Oral <br />Contraceptives and Devices and Mail <br />Order (2x copay for 90 day supply) <br />N <br />$15 Primacy 425 Specialist (Par Docs) I <br />Covered <br />N <br />1g�8r <br />2�0 <br />v <br />; <br />(pMNM <br />m <br />.1NN <br />iii <br />CCC <br />not covered <br />Subject to Ded. and Coins. <br />Covered <br />Subject to Ded. and Coins. <br />$200/5400 <br />3 month carryover <br />Covered <br />S15 Primacy 425 Specialist (Par Docs) <br />Covered <br />80%/60% <br />. <br />E <br />C N <br />� <br />Nn <br />N� <br />88 <br />�rt <br />L <br />r <br />a <br />Ammo mem urripui <br />FM: <br />