Schedule of Benefits I
	PREFERRED PROVIDERS	NON-PREFERRED PROVIDERS
MAXIMUM LIFETIME BENEFIT AMOUNT	$2,000,000 per person
Note: The maximums listed below are the total for Preferred Provider and Non-Preferred Provider expenses. For example, if a maximum of 60 days is listed twice under a service, the Calendar Year maximum is 60 days total, which may be split between Preferred Provider and Non-Preferred Providers.
DEDUCTIBLE, PER CALENDAR YEAR
Per Person	$500
Per Family Unit	$1,500
The calendar year deductible is waived for the following: -  Prescription drug card benefits -  Wellness Benefit
MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR
Per Person (including deductible)	$5,000	$7,500
Per Family (including deductible)	$10,000	$15.000
The Plan will pay the designated percentage of covered charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of covered charges for the rest of the calendar year. There is no out-of-pocket limit for the following: -          Prescription drug card benefits -          Vision benefits -          Dental benefits -          Plan Exclusions The Preferred Provider and Non-Preferred Provider out-of-pocket maximums are calculated on a combined basis.
COVERED SERVICES
Hospital Services
Room and Board	80%	60%
Intensive Care Unit	80%	60%
Other Inpatient	80%	60%
Outpatient Surgery & Diagnostic	80%	60%
Outpatient Pre-Admission   Testing	80%	60%
Outpatient Urgent Care Room	80%	60%
Outpatient Emergency Room	80% after $100 copay (waived if admitted)	60% after $100 copay (waived if admitted)
Inpatient Rehabilitation Facility	80%	60%
Skilled Nursing Facility	80% 90 days lifetime maximum	60% 90 days lifetime maximum
Physician Services
Inpatient visits	80%	60%
Office visits, labs and x-rays	80%	60%
Surgery	80%	60%
Second Surgical Opinions	80%	60%
Home Health Care	80% 104 visits per calendar year maximum	60%   104 visits per calendar year maximum
Private Duty Nursing	80%	60%
Hospice Care	80%	60%
Ambulance Service	80%
Occupational Therapy	80% $2,500 maximum per year	60% $2,500 maximum per year
Speech Therapy (due to accident or illness)	80% $2,500 maximum per year	60% /$2,500 maximum per year
Physical Therapy	80% 15 visits per calendar year maximum	60% 15 visits per calendar year maximum
Chiropractic Services	80%   $1,000 maximum	60%   $1,000 maximum
Durable Medical Equipment	80%	60%
Prosthetics	80%	60%
Orthotics	80% $3,000 maximum benefit per calendar year	60% $3,000 maximum benefit per calendar year
Medical Supplies	80%	60%

Schedule of Benefits I (continued)	PREFERRED PROVIDERS	NON-PREFERRED PROVIDERS
Hearing Aids	80% $1,500 maximum benefit each 5 - year period
Corrective Vision Eye Surgery (correction of nearsightedness or farsightedness only)	80% $1,600 maximum benefit per eye per lifetime	60% $1,600 maximum benefit per eye per lifetime
Infertility Testing (excluding treatment)	80%	60%
Birthing Center	80%	60%
Voluntary Sterilization	80%	60%
Mental Illness
Inpatient	80%	60%
Outpatient Treatment	80%	60%
Partial Hospitalization	80%	0%
Substance Abuse
Inpatient	80%	60%
Outpatient Treatment	80%	60%
Partial Hospitalization	80%	60%
Wellness Benefit  (Medical Services Only)	100% (not subject to deductible) routine colonoscopy, mammogram, pap test, PSA and blood profiles as well as HPV vaccine (when administered according to medical guidelines) are covered under wellness benefit when considered as routine services
Organ Transplants (Refer to Page 32)	80% if performed at Center of Excellence $10,000 per year and $30,000 per lifetime for follow-up care for all transplants combined	90% up to $35,000 per lifetime for all transplants combined $10,000 per year and $30,000 per lifetime for follow-up care for all transplants combined
All Other Covered Services	80%	80%