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Attachment 4 20 <br /> September 5, 1995 <br /> Differences Between Healthsource and <br /> the Blue Cross/ Blue Shield Personal Care Plan <br /> Category Personal Care Plan Healthsource Plan <br /> Lifetime Maximum Unlimited proposed 1/1/96 Unlimited <br /> (currently $1,000,000) <br /> Physician Services <br /> Specialist Referrals Written referrals good for 6 months Paperless referrals <br /> (proposed 1/1/96) <br /> Specialist Visits Fully covered $20 copayment <br /> OB-GYN Visits Unlimited self referrals Unlimited self referrals <br /> (proposed 1/1/96) <br /> After Hours <br /> Physician Visits $15 copayment $20 copayment <br /> Allergy Injections Fully covered Up to $10 per injection <br /> separate cost from <br /> office copayment <br /> Mammograms Fully covered No cost except for office <br /> copayment <br /> Emergency Services <br /> And Out of Area <br /> ER Visit $25 copayment $50 copayment <br /> (waived if admitted) <br /> Urgent Care Centers Not covered $25 copayment <br /> Out of Area <br /> Non-emergency Toll-free out of area network Not available <br />