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Open Access Aetna Select (EPO) Summary of Benefits

IN-NETWORK COVERAGE ONLY

Deductible Single Family Coinsurance Limit Single Family Lifetime Maximum Benefit Primary Care Physician Visits Office Visits Specialty Care Office Visits Diagnostic Lab and X-rays Physical, Occupational, Speech Therapy Preventive Care Routine Physicals Mammogram Routine Eye Exam (any licensed vision care provider) Routine Ob/Gyn Exam Well-Child Care 0­21 years Outpatient Surgery Hospitalization Emergency Treatment Emergency Hospital Charges* Emergency Physician Services* Urgent Care Centers Maternity First Ob/Gyn Visit & Hospital st 1 Ob/Gyn visit Hospital/Global Maternity Charge Behavioral Health Inpatient Outpatient Chiropractic Care Acupuncture for Chronic Pain Durable Medical Equipment Diabetic Supplies $0 $0 N/A N/A Unlimited $15 copay $25 copay No copay $25 copay $0 No copay Aetna pays up to $45; member responsible for balance No copay No copay No copay No copay $50 copay (waived if admitted) $50 copay (waived if admitted) $20 copay

$25 copay No copay 100% up to 365 days $15 copay No copay No copay No copay No copay

*A penalty applies for non-emergency use of emergency hospital services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage.

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