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Benefits Changes <br /> Blue Cross Preferred Provider Plan (PPO), Blue Options Plan 1 and Blue Options Plan 2 <br /> Services Preferred Provider Plan Option 1 -Blue Options Plan 1 Options 2&3-Blue Options Plan 2 <br /> In-Network Out-of-Network in-Network Out-of-Network In-Network Out-of-Network <br /> Other Providers-Home Health 90%after deductible;no 70%after deductible;no visit 90%after deductible;no 70%after deductible;no 4 <br /> Care/Home Care Agencies 90%after deductible 80%after deductible visit limits per benefit period limits per benefit period visit limits,per benefit period visit limits per benefit period <br /> Durable Medical Equipment 90%after deductible 80%after deductible 90%after deductible 70%after deductible 90 6h after deductible 70%after deductible <br /> Hospice 90%°after deductible 80%after deductible 90%after deductible 70%after deductible 90%after deductible. 70%after deductible <br /> Private Duty Nursing Care 90%after deductible 80%after deductible 906/0 after deductible 70%after deductible 90%after deductible 70%after deductible <br /> Special Services/Providers <br /> Ambulance,prosthetic <br /> appliances,orthotics,dental 80%after deductible 80%after deductible 90%after deductible 70%after deductible 90%after deductible 70%after deductible <br /> services related to accident. <br /> 80%after deductible-70 90%after deductible :60 ` 70%after deductible-60 90%after deductible-60 70%after deductible-60 <br /> Skilled Nursing Facility 80%after deductible p days per benefit period. days per benefit period. <br /> days per benefit period. days per benefit period. days per benefit period. da <br /> Up to$5,000 lifetime. $10 Up to$5,000 lifetime. $10 <br /> copay PMD-$20 copay for ° copay PMD-$20 copay for ° <br /> Infertility&Sexual Dysfunction 90%after deductible 70%after deductible 70%after deductible 70%after deductible <br /> specialist. Hospital-90% specialist. Hospital-90% <br /> after deductible .;:. ,. after deductible <br /> Blood/Blood Derivatives 80%after deductible 90°k after deductible 70%after deductible 90%after deductible 70%after deductible <br /> Medical Supplies 80%after deductible 80%after deductible 90%after deductible 70%after deductible 90%,after deductible 70%after deductible <br /> Mental Health/Chemical <br /> Dependency <br /> 90%after deductible-limit 80%after deductible-limit 90%coinsurance{30 days 70%coinsurance(30 days 90%coinsurance(30 days 70%coinsurance(30 days <br /> Mental Health-Inpatient 10 days per year preferred 10 days per year preferred per benefit period preferred per benefit period preferred per benefit period preferred per benefit period preferred <br /> and nonpreferred. and nonpreferred. and nonprefened) and nonpreferred) and nonpreferred) and nonpreferred) <br /> Mental Health-Outpatient 70 after deductible-limit 50 after deductible-limit $ <br /> 20 visits 20 visits 20 copay(certified) 70%coinsurance $20 copay(certified) 70%coinsurance <br /> Chemical Dependency-Inpatient 90%after deductible 80%after deductible 90%coinsurance` 70%coinsurance 90%coinsurance 70%coinsurance <br /> Chemical Dependency- <br /> Outpatient 90%after deductible 80%after deductible $20 copayment 70%coinsurance T$20 copayment 70%coinsurance <br /> r-= <br /> heal ppocom p 10/3/2002 <br />