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Benefits Summary

Personal Choice® PPO

Benefits Personal Choice 5 Personal Choice 15 Personal Choice 10/20/70 Personal Choice 1020/80/50
  In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Deductible Ind/Family NONE $250/$500 NONE $250/$500 NONE $300/$600 $1,000/$2,000 (in-network/out-of-network combined)
After Deductible, Plan Pays 100% 80% 100% 80% 100% 70% 80% 50%
Out of Pocket Ind/Family NONE $1,000/$2,000 NONE $1,000/$2,000 NONE $2,000/$4,000 $3,000/$6,000 $10,000/$20,000
Overall Lifetime Maximum Unlimited $1 Million Unlimited $1 Million Unlimited $1 Million Unlimited $500,000
Primary Care Provider Office Visit $5 80% $15 80% $10 70% $20 50%
Specialist Visit $5 80% $15 80% $20 70% $30 50%
Inpatient Hospital Care 100% 80% 100% 80% $75 per day, $375 per adm 70% 80% 50%
Lab 100% 80% 100% 80% 100% 70% 100% 50%
Preventive Care Office Visits $5 80% $15 80% $10 70% $20 50%
Routine Gyn Exam/Pap Smear 100% 80% 100% 80% 100% 70% 100% 50%
Maternity Care: First OB Visit $5 (100% thereafter) 80% $15 (100% thereafter) 80% $10 (100% thereafter) 70% $20 (100% thereafter) 50%
Maternity care: Inpatient Hospital 100% 80% 100% 80% $75 per day, $375 per adm 70% 80% 50%
Emergency Care $25 (waived if admitted) $25 (waived if admitted) $40 (waived if admitted) $40 (waived if admitted)

The above table illustrates some of the benefit programs available. This plan may not cover all your health care expenses. This information has been extracted from and is subject to the terms and conditions of all applicable group contracts and member handbooks.

For more information on the terms, limitations, and exclusions of the benefit programs, please contact your independent broker, or call 1-215-241-3400.

Personal Choice PPO programs are underwritten or administered by QCC Insurance Company, Inc.