Page 55

55 certain conditions are met) Chiropractic Care 90% of MAC; Maintenance visits not covered when no additional progress is apparent or expected to occur 70% of MAC; Maintenance visits not covered when no additional progress is apparent or expected to occur $20 copay; Maintenance visits not covered when no additional progress is apparent or expected to occur 70% of MAC after deductible; Maintenance visits not covered when no additional progress is apparent or expected to occur $15 copay; Maintenance visits not covered when no additional progress is apparent or expected to occur Ambulance Service – Air & Ground 80% of reasonable charges when deemed medically necessary by claims administrator 100% of reasonable charges when deemed medically necessary by claims administrator 100% of reasonable charges when deemed medically necessary by claims administrator Lab and X-ray 90% of MAC 70% of MAC 100% benefit 70% of MAC after deductible 100% benefit Physical, Speech & Occupational Therapy 90% of MAC; Some limitations may apply 70% of MAC; Some limitations may apply $20 copay per visit; Limited to 45 visits per year per condition 70% of MAC; Limited to 45 visits per year per condition after deductible $15 copay per visit; Limited to 45 visits per year per condition Mental Health Inpatient* (preauthorization required) 90% of MAC; Limited to 45 days per year 70% of MAC; Limited to 45 days per year $100 copay per admission; Limited to 30 days per year Not covered $100 copay per admission; Limited to 30 days per year Substance Abuse Inpatient* (preauthorization required) 90% of MAC; Limited to two 5-day detox stays per lifetime; plus two 28- day lifetime stays 70% of MAC; Limited to two 5-day detox stays per lifetime; plus two 28- day lifetime stays $100 copay per admission; Limited to two 5-day detox stays per lifetime; plus two 28-day lifetime stays Not covered $100 copay per admission; Limited to two 5-day detox stays per lifetime; plus one 28-day lifetime stay Mental Health/Substance Abuse Outpatient* (preauthorization required) 1-15: $5 copay/session 16-45: $25 copay/session Limited to 45 sessions mental 1-15: $40 copay/session 16-45: $100 copay/session Limited to 45 sessions mental $25 copay per session; Limited to 45 sessions mental health and substance abuse combined Not covered $20 copay per session; Limited to 45 sessions mental health and substance abuse combined