Blue Medallion

Extended Health Care Benefits Rider

Deductible

$100 Individual / $200 Family

20% coinsurance

Extended Coverage for your Protection

The Extended Health Care Benefits Rider supplements BlueCross BlueShield’s Basic Hospital and Medical/Surgical coverage. This plan provides for extended hospitalization when a member requires additional health care. It also increases allowances for basic benefits and provides additional services. Most benefits are subject to deductible and coinsurance

Deductible Amount And Coinsurance

The deductible is the amount the member pays for covered medical expenses before being eligible for reimbursement under the Extended Health Care Benefits Rider. The deductible amount is payable only once in each calendar year. If two or more covered members of a family are injured in the same accident, occurring on or after the effective date of their coverage, only one cash deductible amount will apply to expenses incurred as a result of the accident.

For other than a common accident as explained above, there is a separate deductible for each covered member of a family, but limited to three deductibles per family per year. In larger employer groups an aggregate (combined) family deductible may apply.

The coinsurance is the percentage of covered medical expenses in excess of the deductible amount which is the responsibility of the member. The coinsurance is 20% of the first $2000 of covered medical expenses. After $2000 of covered medical expenses (or $400 out-of-pocket) is incurred in a calendar year, BlueCross BlueShield will cover 100% of the allowed amounts to the end of the same calendar year for that member.

Coverage Includes:

· Doctors services for Medical and for Surgical Care in a Hospital, in the Home, and in the Doctor’s Office

· Well Care (Age 0-19 with Immunizations)

· Annual Gyn Exam/Pap Smear

· Inpatient Hospital Service as described in the Basic Hospital Services Contract (an Additional $10.00 per Day will be paid when confined in a private room)

· Blood Transfusions (Includes cost of Blood/Plasma)

· Diagnostic X-Ray and other Radiology Services

· Laboratory and Pathology Tests

· Therapies: Physical, Radiation, Speech , Chemotherapy, Cardiac

Rehabilitation

· Diabetic Treatment, Equipment, Supplies, and Self-Management Education

· Rental or Purchase of Durable Medical Equipment required for Temporary use for Restorative Purposes

· Professional Ground Ambulance Service used Locally to or from Hospital when related to Inpatient Care (Also for Outpatient Care in Accidental Bodily Injury Cases)

· Prosthetic Devices, when Prescribed by a Doctor to Relieve or correct a Condition caused by an Injury or Illness

· Private Duty Nursing

· Vision Care

· Home Health Care Service Benefits as Described in the Basic Hospital Service Contract (Limited to an additional 40 Home Care visits per calendar year, per Member)

· Mental Disorders--Hospital Treatment: 90 additional days per calendar year

· Acute Care General Hospital -- (Benefit is for treatment received as an inpatient in an institution having Full Hospital Facilities but which Primarily does not Provide Treatment for Mental Disorders)

· Inpatient Mental Health Treatment at Psychiatric Facility 60 days

· Prescription Medications, unless provider under separate rider.

· Extraction of Impacted Wisdom Teeth

· Mental Health Care

Þ 30 Outpatient Visits

Þ $10.00 for a doctors visit with $500.00 per calendar year maximum

Prospective Rates	PE6500	Major Medical Extended Health Care Benefit $100 Deductible, 80/20 Coinsurance	Total
Individual	$164.87	$224.80	$389.67
Two Person	$333.89	$449.60	$783.49

Retrospective with Deferral – 80% Rates	PE6500	Major Medical Extended Health Care Benefit $100 Deductible, 80/20 Coinsurance	Total
Individual	$132.54	$179.84	$312.38
Two Person	$269.22	$359.68	$628.90

The above rates include organ and bone marrow transplant reinsurance. Minimum participation must be met at time of enrollment. Rates assume employer contribution remains the same percentage as current.