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Summary of Benefits and Copayments For Plans "A" ,"B" and "C"

*Copayment

OUTPATIENT SERVICES	COPAYMENTS PLAN "A"	COPAYMENTS PLAN "B"	COPAYMENTS PLAN "C"
Primary Care Physician Services	$ 5.00 per visit	$ 10.00 per visit	$ 10.00 per visit
Specialist Physician Services	$ 10.00 per visit	$10.00 per visit	$ 10.00 per visit
Sub-Specialist Physician Services	$ 50.00 per visit	$ 50.00 per visit	$ 50.00 per visit
Surgical Services	No Charge	$ 50.00 per visit	$ 50.00 per visit
Treatment rooms & all appropriate equipment	No Charge	No Charge	No Charge
Application,changes,removal of dressings,splints,plaster cast,& removal of sutures	No Charge	No Charge	No Charge
Medical supplies for use at provider's office/Facility	No Charge	No Charge	No Charge
Laboratory examinations and services	No Charge	No Charge	No Charge
Periodic physical examinations	No Charge	No Charge	No Charge
Well child care and pediatric services	No Charge	No Charge	No Charge
Health education	No Charge	No Charge	No Charge
Immunizations	No Charge	No Charge	No Charge
Allergy testing Allergy visits & Immunotherapy	$ 50 per vivit $ 10 per visit	$ 50 per visit $ 10 per visit	$ 50 per visit $ 10 per visit
Chiropractic and Podiatric services	$ 10.00 per visit	$ 10.00 per visit	$ 10.00 per visit
Routine vision & Hearing examinations	$ 5.00 per visit	$ 5.00 per visit	$ 5.00 per visit
Therapeutic & Diagnostic Services	*Copayment	*Copayment	*Copayment
Major Procedures & Surgeries	*Copayment	*Copayment	*Copayment
INPATIENT HOSPITAL SERVICES
Semi-privare room,board,nursing care,& meals	No Charge	No Charge	No Charge
Intensive,critical,special & coronary care units	*Copayment	*Copayment	*Copayment
Operating,treatment & recovery rooms	No Charge	No Charge	No Charge
Application,change & removal of dressings,splints,plaster casts & removal of sutures	No Charge	No Charge	No Charge
Drugs,medicine,intravenous injections & solutions prescribed by attending physician for use in the hospital	No Charge	No Charge	No Charge
Medical supplies for use in the hospital	No Charge	No Charge	No Charge
Oxygen and its administration	No Charge	No Charge	No Charge
Laboratory examinations, electrocardiograms & inhalation therapy	No Charge	No Charge	No Charge
MATERNITY	*Copayment	*Copayment	*Copayment
EMERGENCY SERVICES & CARE, and hospital stays Initiated through the Emergency Room, Including Emergency Ambulance Services
Coverage within the USA only	$ 100 per emergency plus 25% of charges above $ 100	$ 100 per emergency plus 25% of charges above $ 100	$ 250 per visit
PRESCRIPTIONS Generic Prescription Drugs except non-generic,non-prescriptions & contraceptives	$10/$15/$20/$30 or 50% per prescription at plan "A" PCP Offices	$10/$15/$20/$30 or 50%per prescription at PMP participating pharmacies	$10/$15/$20/$30 or 50%per prescription at PMP participating pharmacies
OPTIONAL RIDERS AVAILABLE
Coverage for eye glasses	$ 10.00 Copayment	$ 10.00 Copayment	$ 10.00 Copayment
Dental	See Dental Brochure	See Dental Brochure	See Dental Brochure

*The sum of all co-payments will not exceed $3,000.00 per member or $ 6,000.00 per family per calendar year, except these limits are not applicable to co-payments for emergency care Services and Second Medical Opinions. This is not a contract. All services must be preauthorized by the health plan except for emergency care.For specifics on benefit , co-payment, limitations and exclusions, please see the current Preferred Medical Plan , Inc. Medical & Hospital Services Contract. Above benefits based on PMP FORM # PMP HOSP. #.1/2-05, ATT-A-8/05 ET.AL. Prices subject to change. You may contact PMP at (305) 648-4015, if you have questions.

FORM NO. PMP/MK/SumBen-A-B/ENG(08/05)

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