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19 <br /> Section B: Special Services/Providers <br /> Services listed below requires only a$200 deductible for an individual and $600 for family for the <br /> plans listed. A separate deductible is not required. Additionally, the coinsurance is 20 percent. <br /> Category Traditional Plan PPO PPO <br /> Preferred Non-Preferred <br /> Ambulance Services 80% PRC 80%PRC 80% PRC <br /> Prescription <br /> Services <br /> Participating pharmacies <br /> as designated by the plan <br /> (Result: less out-of- <br /> pocket cost and <br /> simpler claim filing) <br /> or <br /> Non-participating pharmacies <br /> (Result: greater out-of- <br /> pocket cost and more <br /> complex claim filing) <br /> Prescription charges 80% PRC 80%PRC 80%PRC <br /> Oral Contraceptives/ Not Covered Not Covered Not Covered <br /> Fertility Drugs <br /> Prosthetic/Orthopedic <br /> Devices <br /> When 80%PRC 80%PRC 80%PRC <br /> medically necessary <br /> Dental <br /> Accidental injury 80%PRC 80%PRC 80%PRC <br /> Skilled Nursing <br /> Facility 80% PRC 80%PRC 80% PRC <br /> Up to 70 days in a semi- <br /> private facility (After <br /> 70 days, additional days <br /> allowed if hospitalized) <br />