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Benefits Changes <br /> Blue Cross PCP, Blue Care Plan 1 and Blue Care Plan 2 <br /> Services Personal Care Plan (PCP) Option 1 - Blue Care Plan 1 Options 2 & 3 - Blue Care Plan 2 <br /> Tier 1 $12 Copay; Tier 2 $24 Copay; Tier Tier 1 $15 Copay; Tier 2 $45 Copay;Tier Tier 1 $30 Copay;Tier 2 $60 Copay;Tier <br /> Extended Supply Benefits 3 $36 Copay(35-90 Day Supply) 3 $90 Copay(31-90 Day Supply) $90 Copay(31-90 Day Supply) <br /> Other Providers <br /> Home Health/Home Care 100% (60 Days Maximum Per Calendar <br /> Agencies Year) 100% (No Days Maximum Per Cal Yr) 100% after deductible <br /> 100% (60 Days Maximum Per Calendar 100% after deductible (60 Day Maximum Per <br /> Skilled Nursing Facility Year) 100% (60 Day Maximum Per Cal Yr) Cal Yr) <br /> Durable Medical Equipment 100% ($3,000 maximum per Calendar <br /> Suppliers Year) 100% (No Maximum Per Cal Yr) 100%after deductible <br /> $10 Copay PMD; $20 Specialist; Hosp Svcs. <br /> $10 Copay PMD; $20 Specialist; Hosp 100%after ded., Inp&Outpt Prof 100% after <br /> Infertility 50% Svcs. 100%, Inp&Outpt Prof 100% ded. <br /> Infertility Lifetime Maximum of$10, 000 Lifetime Maximum of$5, 000. Lifetime Maximum of$5,000 <br /> Mental Health Services <br /> $100 Copay Per Day-30 Days Maximum <br /> Inpatient Per Calendar Year 100%-30 Days Maximum Per Cal Yr 100%, 30 Days Maximum Per Cal Yr <br /> $20 Copay(1-20 visits)$30 Copay(21-30 <br /> Outpatient- Individual Therapy Visits-30 Visits Maximum Per Calendar $20 Copay-30 Visits Maximum Per Cal <br /> Visits Year Combined Individual Therapy Yr $20 Copay-30 Visits Maximum Per Cal Yr <br /> $10 Copay for 1-20 Visits. $15 Copay for <br /> Group Therapy Visit 21-30 Visits. Not Separate for Group vs Individual Not Separate for Group vs Individual ' <br /> 100% -30 Days Maximum Per Cal Yr <br /> Chemical Dependency Services 100% (no day limit) Inpatient/Outpatient combined <br /> Office Visit $10 Copay $20 Copay $20 Copay <br /> $100 Copay Per Day-30 Days Maximum <br /> Per Calendar Year with $8,000 Cal Yr Max 100%with $8,000 Cal Yr Max and 100%with $8,000 Cal Yr Max and $16,000 <br /> Inpatient/Outpatient and $16,000 Lifetime Max $16,000 Lifetime Max Lifetime Max' <br /> Chiropractic $20 Copay $20 Copay; 20 visits per policy year $20 Copay(Max 20 visits per Cal Yr) ., <br /> Transplants Covered 100% 100% after deductible <br /> 4th Quarter Carryover Yes No No <br /> PMD = Primary Care Doctor <br /> Note: Shows benefit changes for Blue Care Plan 1 as compared to PCP and for Blue Care Plan 2 as compared to PCP and Blue Care Plan 1. <br /> heal pcpcomp10/3/2002 ° <br />