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23 <br /> Category Personal Care Plan Healthsource Plan <br /> Dental Accidental injury only except: Repair of fractures and <br /> under age 19 congenital defects removal of tumors and <br /> or abnormalities covered cysts. <br /> Accidental injury: <br /> Services to repair sound, <br /> natural teeth rendered within <br /> 48 hours of injury. <br /> Copayment based on place <br /> of service <br /> Medical Supplies <br /> Medical Equipment Fully covered when medically 25%copayment per item <br /> Prosthetic/Orthopedic necessary up to $2,500 per year <br /> Devices <br /> Wellness 24 Hour Nursing Telephone Line In-house and worksite <br /> Self-Care Book Health Education Programs <br /> Health Risk Appraisals <br /> Topic-Specific Materials <br /> (all proposed 9/1/95) <br /> Conversion After COBRA expires, After COBRA expires, <br /> conversion to non-group plan conversion to another <br /> with Blue Cross& Blue Shield health insurance company <br /> with HMO benefits continued occurs and HMO benefits <br /> are no longer an option <br /> Medicare Supplement Provides Medicare Supplement Plan No Medicare Supplement Plan <br />