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JR;ryQ><;@*68zߘ#(DZ*U.W~ѴҺW%ź~"~ P~C ok1V&C:;o|w]Z$爐D'w4?)̰`ӧԳ$>*U.ٵ绺َ($CK/+ηߙ>iԴk]>/2_]Ak1v6e^5q:xD4}Ϟk_,uS1??{qV'v1K{W~IĒBѽGP 8Oq}5ag3Z./H=|~,_]j:6y-܎ݤbc4S%6p7ο^Sط?+KcnKi% N=(p?!NO,qqd#g{=߲=O0*O#a2C$E,LRXee4 T!bJf&>a׿M34vkBfY-ݢ֛$hъE HRfc#q/Kk6q y~iXj]wnoޟ{LpA҉> Fp%4(eciZ4g. {2|ukDA8e"FQ_=gt}>l;#*EҨκ?5/ӛN<_0-SSF>tu VnxtC*h#bz vU9p2v}G^Ќ98J$z50ݫ<^L8r$y>< ,Z60xKyBs,!9O~!y:o/3i6'F׶ r6EZož gU tU{Cŋ?27ʿ]{}ٝVl`3DĀwK4F.nG);\Ϭz]Wy}U[~s] үwG] f}nQ)s,+ wOc_o { ~8 SX8W/#DM+}{w>?[/S^ى}wBywVF> U{,r_ endstream endobj 10 0 obj <>/Border[ 0 0 0]/StructParent 0/Rect[ 564.65 482.15 634.63 496.05]/Contents(w w w dot m e s s a dot o r g)/Subtype/Link>> endobj 12 0 obj <>/Border[ 0 0 0]/StructParent 1/Rect[ 191.02 454.61 367.14 468.38]/Contents(Health Care dot Gov S B C Glossary of terms)/Subtype/Link>> endobj 15 0 obj <>stream q 0 0 792 612 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 18 18 cm 0 0 0 rg BT /F3 12 Tf 1 0 0 1 0 3.83 Tm ( ) Tj ET BT /F4 12 Tf 1 0 0 1 3 3.83 Tm (Group Number 71452, 71453 - 225/226 ) Tj ET BT /F5 12 Tf 1 0 0 1 601.9 3.96 Tm (SBC000008046115 ) Tj ET 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 720.57 3.83 Tm (1) Tj ET BT /F4 12 Tf 1 0 0 1 726.05 3.83 Tm ( ) Tj ET BT /F5 12 Tf 1 0 0 1 728.78 3.83 Tm (of) Tj ET BT /F4 12 Tf 1 0 0 1 736.99 3.83 Tm ( ) Tj ET BT /F4 12 Tf 1 0 0 1 739.73 3.83 Tm (8 ) Tj ET Q q Q EMC q 1 0 0 1 18 33.02 cm /Artifact <> BDC 0.94902 0.94902 0.94902 RG 0 J 3.6 w -10.25 503.5 m 760 503.5 l S 1 w 0.58431 0.70196 0.84314 RG 3.6 w -10.25 499.9 m 760 499.9 l S 1 w EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -4.5 559.34 Tm (Summary of Benefits and Coverage: ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 167.74 559.34 Tm (What this Plan Covers & What You Pay ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 342.77 559.34 Tm (f) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 345.51 559.34 Tm (or Covered Services ) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 477 559.28 Tm (Coverage Period: ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 561.21 559.28 Tm (Beginning on or after 01/01/2026 ) Tj ET EMC q 1 0 0 1 -4.5 506 cm q n 0 0 m 114.55 0 l 114.55 45.05 l 0 45.05 l h W n /Figure <>BDC q 114.55 0 0 45.05 0 0 cm /img12335 Do Q EMC Q Q q Q /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F4 16 Tf 1 0 0 1 138.6 535.79 Tm (MESSA Balance & Balance RX ) Tj ET EMC q 1 0 0 1 641.2 527.14 cm q n 0 0 m 111.6 0 l 111.6 28.8 l 0 28.8 l h W n /Artifact <> BDC q 111.6 0 0 28.8 0 0 cm /img12336 Do Q EMC Q Q q Q /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 138.6 511.91 Tm (PPO ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 476 511.98 Tm (Coverage for:) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 539.97 511.98 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 542.7 511.98 Tm (Individual/Family) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 615.99 511.98 Tm ( | ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 624.02 511.98 Tm (Plan Type:) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 673.78 511.98 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 676.52 511.98 Tm (PPO ) Tj ET EMC /Artifact <> BDC 0.93725 0.97647 1 RG 0 J 27.54 w -6.63 476.79 m 48.03 476.79 l S 1 w 27.54 w 48.03 476.79 m 762.13 476.79 l S 1 w 41.44 w -6.63 442.3 m 762.13 442.3 l S 1 w EMC /Span <>BDC BT /F8 4 Tf 1 0 0 1 -1.48 463.56 Tm ( ) Tj ET EMC q 1 0 0 1 2.97 463.56 cm q n 0 0 m 36.2 0 l 36.2 27 l 0 27 l h W n /Artifact <> BDC q 36.2 0 0 27 0 0 cm /img12338 Do Q EMC Q Q q Q /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 53.43 479.37 Tm (The Summary of Benefits and Coverage \(SBC\) document will help you choose a health ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 461.35 479.37 Tm (plan) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG 461.79 477.66 m 481.14 477.66 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 481.58 479.37 Tm (. The SBC shows you how you and the ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 664.76 479.37 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 665.2 477.66 m 684.55 477.66 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 685 479.37 Tm ( would share ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 53.43 465.6 Tm (the cost for covered health care services. NOTE: Information about the cost of this ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 442.22 465.6 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 442.66 463.89 m 462.02 463.89 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 462.46 465.6 Tm ( \(called the ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 516.6 465.6 Tm (premium) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 517.04 463.89 m 557.72 463.89 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 558.16 465.6 Tm (\) will be provided separately. ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -1.48 451.83 Tm (This is only a summary. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 112.84 451.83 Tm (For more information about your coverage, or to get a copy of the complete terms of coverage, visit ) Tj ET EMC /Span <>BDC 0 0 1 rg BT /F5 12 Tf 1 0 0 1 546.65 451.83 Tm (www.messa.org) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 1 RG 547.09 450.12 m 616.19 450.12 l S 1 w [] 0 d EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 616.63 451.83 Tm ( or call ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 648.35 451.83 Tm (MESSA at 1-800-336- ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 -1.48 438.06 Tm (0013) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 20.42 438.06 Tm (. For general definitions of common terms, such as ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 244.14 438.06 Tm (allowed amount) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 0 RG 244.58 436.35 m 312.63 436.35 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 313.07 438.06 Tm (, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 318.54 438.06 Tm (balance billing) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 318.98 436.35 m 380.47 436.35 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 380.91 438.06 Tm (, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 386.38 438.06 Tm (coinsurance) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 386.82 436.35 m 439 436.35 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 439.44 438.06 Tm (, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 444.92 438.06 Tm (copayment) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 445.36 436.35 m 492.62 436.35 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 493.06 438.06 Tm (, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 498.53 438.06 Tm (deductible) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 498.97 436.35 m 542.95 436.35 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 543.39 438.06 Tm (, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 548.87 438.06 Tm (provider) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 549.31 436.35 m 583.98 436.35 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 584.42 438.06 Tm (, or other ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 626.54 438.06 Tm (underlined) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 626.98 436.35 m 672.05 436.35 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 672.49 438.06 Tm ( terms see the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 -1.48 424.29 Tm (Glossary. You can view the Glossary at ) Tj ET EMC /Span <>BDC 0 0 1 rg BT /F5 12 Tf 1 0 0 1 173.02 424.29 Tm (https://www.healthcare.gov/sbc-glossary) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 1 RG 173.46 422.58 m 348.7 422.58 l S 1 w [] 0 d EMC /Span <>BDC 0 0 0 rg BT /F5 9 Tf 1 0 0 1 349.14 424.29 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 351.2 424.29 Tm (or call) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 377.45 424.29 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 380.18 424.29 Tm (MESSA at 1-800-336-0013) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 498.34 424.29 Tm ( to request a copy. ) Tj ET EMC /Artifact <> BDC 0.5 w [] 0 d 0.75294 0.9098 0.98431 RG -6.88 490.56 m -6.88 421.58 l S 1 w [] 0 d 0.5 w [] 0 d 762.38 490.56 m 762.38 421.58 l S 1 w [] 0 d 0.5 w [] 0 d -6.88 490.81 m 762.38 490.81 l S 1 w [] 0 d 0.5 w [] 0 d -6.88 421.33 m 762.38 421.33 l S 1 w [] 0 d EMC /Artifact <> BDC 0.02745 0.45882 0.65882 RG 0 J 34.02 w -4.43 402.43 m 156.77 402.43 l S 1 w 16.7 w 157.52 411.09 m 345.77 411.09 l S 1 w 34.02 w 346.52 402.43 m 759.67 402.43 l S 1 w 16.7 w 157.52 393.76 m 251.27 393.76 l S 1 w 16.7 w 252.02 393.76 m 345.77 393.76 l S 1 w 1 1 1 RG 34.44 w -4.43 367.45 m 156.77 367.45 l S 1 w 34.44 w 157.52 367.45 m 251.27 367.45 l S 1 w 34.44 w 252.02 367.45 m 345.77 367.45 l S 1 w 34.44 w 346.52 367.45 m 759.67 367.45 l S 1 w 0.93725 0.97647 1 RG 57.85 w -4.43 321.05 m 156.77 321.05 l S 1 w 57.85 w 157.52 321.05 m 345.77 321.05 l S 1 w 57.85 w 346.52 321.05 m 759.67 321.05 l S 1 w 1 1 1 RG 32.8 w -4.43 275.6 m 156.77 275.6 l S 1 w 32.8 w 157.52 275.6 m 345.77 275.6 l S 1 w 32.8 w 346.52 275.6 m 759.67 275.6 l S 1 w 1.1 w -4.43 258.65 m 157.02 258.65 l S 1 w 1.1 w 157.27 258.65 m 346.02 258.65 l S 1 w 1.1 w 346.27 258.65 m 759.67 258.65 l S 1 w 0.93725 0.97647 1 RG 57.98 w -4.43 228.61 m 156.77 228.61 l S 1 w 57.98 w 157.52 228.61 m 251.27 228.61 l S 1 w 57.98 w 252.02 228.61 m 345.77 228.61 l S 1 w 57.98 w 346.52 228.61 m 759.67 228.61 l S 1 w 1 1 1 RG 44.21 w -4.43 177.02 m 156.77 177.02 l S 1 w 44.21 w 157.52 177.02 m 345.77 177.02 l S 1 w 44.21 w 346.52 177.02 m 759.67 177.02 l S 1 w 0.93725 0.97647 1 RG 75.75 w -4.43 116.29 m 156.77 116.29 l S 1 w 75.75 w 157.52 116.29 m 345.77 116.29 l S 1 w 75.75 w 346.52 116.29 m 759.67 116.29 l S 1 w 1 1 1 RG 30.44 w -4.43 62.45 m 156.77 62.45 l S 1 w 30.44 w 157.52 62.45 m 345.77 62.45 l S 1 w 30.44 w 346.52 62.45 m 759.67 62.45 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F8 12 Tf 1 0 0 1 -3.35 398.46 Tm (Important Questions ) Tj ET EMC /Span <>BDC BT /F8 12 Tf 1 0 0 1 226.64 407.12 Tm (Answers ) Tj ET EMC /Span <>BDC BT /F8 12 Tf 1 0 0 1 503.1 398.46 Tm (Why this Matters: ) Tj ET EMC /Span <>BDC BT /F8 12 Tf 1 0 0 1 173.4 389.8 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F8 12 Tf 1 0 0 1 255.24 389.8 Tm (Out-of-Network ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -3.35 363.14 Tm (What is the overall ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 86.34 363.14 Tm (deductible) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG 86.78 361.43 m 135.11 361.43 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 135.55 363.14 Tm (? ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 370.15 Tm ($1,700 Individual/ ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 356.38 Tm ($3,400 Family ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 253.1 370.15 Tm ($3,400 Individual/ ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 253.1 356.38 Tm ($6,800 Family ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 370.15 Tm (Generally, you must pay all of the costs from ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 544.53 370.15 Tm (providers) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 544.97 368.44 m 584.56 368.44 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 585 370.15 Tm ( up to the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 628.79 370.15 Tm (deductible) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 629.22 368.44 m 673.21 368.44 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 673.65 370.15 Tm ( amount before this ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 356.38 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 348.04 354.67 m 365.76 354.67 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 366.2 356.38 Tm ( begins to pay. ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.35 323.56 Tm (Are there services covered before ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.35 309.79 Tm (you meet your ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 66.65 309.79 Tm (deductible) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 67.08 308.08 m 115.42 308.08 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 115.86 309.79 Tm (? ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 323.69 Tm (Yes. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 181.03 323.69 Tm (Preventive care) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 181.47 321.98 m 248.96 321.98 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 249.4 323.69 Tm ( services are covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 309.92 Tm (before you meet your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 254.34 309.92 Tm (deductible) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 254.77 308.21 m 298.76 308.21 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 299.2 309.92 Tm (. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 337.46 Tm (This ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 368.93 337.46 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 369.37 335.75 m 387.09 335.75 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 387.53 337.46 Tm ( covers some items and services even if you havent yet met the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 669.26 337.46 Tm (deductible) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 669.7 335.75 m 713.69 335.75 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 714.13 337.46 Tm ( amount. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 323.69 Tm (But a ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 373.32 323.69 Tm (copayment) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 373.76 321.98 m 421.02 321.98 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 421.46 323.69 Tm ( or ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 435.68 323.69 Tm (coinsurance) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 436.12 321.98 m 488.3 321.98 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 488.74 323.69 Tm ( may apply. For example, this ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 620.02 323.69 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 620.46 321.98 m 638.18 321.98 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 638.62 323.69 Tm ( covers certain ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 705.36 323.69 Tm (preventive ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 705.79 321.98 m 750.32 321.98 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 309.92 Tm (services) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 348.04 308.21 m 383.25 308.21 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 383.69 309.92 Tm ( without ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 420.34 309.92 Tm (cost-sharing) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 420.78 308.21 m 473.51 308.21 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 473.95 309.92 Tm ( and before you meet your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 591.57 309.92 Tm (deductible) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 592.01 308.21 m 636 308.21 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 636.44 309.92 Tm (. See a list of covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 296.15 Tm (preventive services) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 348.04 294.44 m 431.39 294.44 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 431.83 296.15 Tm ( at \() Tj ET EMC /Span <>BDC 0 0 1 rg BT /F5 12 Tf 1 0 0 1 448.79 296.15 Tm (https://www.healthcare.gov/coverage/preventive-care-benefits/) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 1 RG 449.23 294.44 m 720.76 294.44 l S 1 w [] 0 d EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 721.2 296.15 Tm (\). ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.35 278.18 Tm (Are there other ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 69.92 278.18 Tm (deductibles) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 0 RG 70.36 276.46 m 124.16 276.46 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 124.6 278.18 Tm ( for ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.35 264.4 Tm (specific services? ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 278.3 Tm (No. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 271.42 Tm (You dont have to meet ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 451.56 271.42 Tm (deductibles) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 452 269.71 m 500.9 269.71 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 501.34 271.42 Tm ( for specific services. ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.35 244.96 Tm (What is the ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 51.88 244.96 Tm (out-of-pocket limit) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 52.31 243.25 m 137.26 243.25 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 137.7 244.96 Tm ( for ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.35 231.19 Tm (this ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 16.88 231.19 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 17.32 229.48 m 36.67 229.48 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 37.12 231.19 Tm (? ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 -3.35 217.55 Tm (\(May include a ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 63.38 217.55 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 63.82 215.84 m 116 215.84 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 -3.35 203.78 Tm (maximum\) ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 231.32 Tm ($4,100 Individual/ ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 217.55 Tm ($8,200 Family ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 253.1 231.32 Tm ($8,200 Individual/ ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 253.1 217.55 Tm ($16,400 Family ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 224.43 Tm (The ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 367.29 224.43 Tm (out-of-pocket limit) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 367.73 222.72 m 444.52 222.72 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 444.96 224.43 Tm ( is the most you could pay in a year for covered services. ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.35 179.6 Tm (What is not included in the ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 124.6 179.6 Tm (out) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 125.03 177.88 m 139.45 177.88 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 10 Tf 1 0 0 1 139.89 179.6 Tm (-) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 140.33 177.88 m 142.18 177.88 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 142.62 179.6 Tm (of) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 143.06 177.88 m 151.47 177.88 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 10 Tf 1 0 0 1 151.91 179.6 Tm (- ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 152.35 177.88 m 154.2 177.88 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.35 165.83 Tm (pocket limit) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d -2.91 164.11 m 50.9 164.11 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 51.34 165.83 Tm (? ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 186.61 Tm (Premiums) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 159.04 184.9 m 202.44 184.9 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 202.89 186.61 Tm (, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 208.36 186.61 Tm (balance-billing) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 208.8 184.9 m 270.82 184.9 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.26 186.61 Tm ( charges, any ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 172.84 Tm (pharmacy) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 159.04 171.13 m 201.37 171.13 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 201.81 172.84 Tm ( penalty and health care this ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 159.07 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 159.04 157.36 m 176.76 157.36 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 177.2 159.07 Tm ( doesnt cover. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 172.84 Tm (Even though you pay these expenses, they dont count toward the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 638.14 172.84 Tm (outofpocket limit) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 638.58 171.13 m 719.76 171.13 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 720.2 172.84 Tm (. ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.35 118.87 Tm (Will you pay less if you use a ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.35 105.1 Tm (network provider) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d -2.91 103.39 m 76.04 103.39 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 76.48 105.1 Tm (? ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 125.88 Tm (Yes. For a list of ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 232.45 125.88 Tm (network providers) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 232.88 124.17 m 309.67 124.17 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 310.11 125.88 Tm ( see ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 112.11 Tm (\() Tj ET EMC /Span <>BDC 0 0 1 rg BT /F5 12 Tf 1 0 0 1 161.88 112.11 Tm (http://www.messa.org) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 1 RG 162.31 110.4 m 256.05 110.4 l S 1 w [] 0 d EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 256.49 112.11 Tm (\) or call MESSA at ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 98.34 Tm (800-336-0013 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 139.65 Tm (This ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 368.93 139.65 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 0 RG 369.37 137.94 m 387.09 137.94 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 387.53 139.65 Tm ( uses a ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 422 139.65 Tm (provider) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 422.44 137.94 m 457.11 137.94 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 457.55 139.65 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 460.29 139.65 Tm (network) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 460.73 137.94 m 494.3 137.94 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 494.74 139.65 Tm (. You will pay less if you use a ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 628.77 139.65 Tm (provider) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 629.21 137.94 m 663.88 137.94 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 664.32 139.65 Tm ( in the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 693.87 139.65 Tm (plan's ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 694.3 137.94 m 718.84 137.94 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 125.88 Tm (network) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 348.04 124.17 m 381.61 124.17 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 382.05 125.88 Tm (. You will pay the most if you use an ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 541.8 125.88 Tm (out-of-network provider) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 542.24 124.17 m 642.54 124.17 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 642.98 125.88 Tm (, and you might receive a ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 112.11 Tm (bill from a ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 392.99 112.11 Tm (provider) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 393.43 110.4 m 428.1 110.4 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 428.54 112.11 Tm ( for the difference between the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 564.23 112.11 Tm (providers) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 564.67 110.4 m 606.44 110.4 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 606.88 112.11 Tm ( charge and what your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 707 112.11 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 707.43 110.4 m 725.16 110.4 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 725.6 112.11 Tm ( pays ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 98.34 Tm (\() Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 350.88 98.34 Tm (balance billing) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 351.31 96.63 m 412.8 96.63 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 413.24 98.34 Tm (\). Be aware, your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 490.91 98.34 Tm (network provider) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 491.35 96.63 m 563.21 96.63 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 563.65 98.34 Tm ( might use an ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 625.47 98.34 Tm (out-of-network provider) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 625.91 96.63 m 726.21 96.63 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 726.65 98.34 Tm ( for ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 84.57 Tm (some services \(such as lab work\). Check with your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 571.29 84.57 Tm (provider) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 571.73 82.86 m 606.4 82.86 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 606.84 84.57 Tm ( before you get services. ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.35 65.02 Tm (Do you) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 30 65.02 Tm ( need a ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 66.65 65.02 Tm (referral) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 67.08 63.31 m 100.11 63.31 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 100.55 65.02 Tm ( to see a ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.35 51.25 Tm (specialist) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d -2.91 49.54 m 41.07 49.54 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 41.51 51.25 Tm (? ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 158.6 58.27 Tm (No. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.6 58.27 Tm (You can see the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 421.47 58.27 Tm (specialist) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 421.91 56.56 m 461.51 56.56 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 461.95 58.27 Tm ( you choose without a ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 559.88 58.27 Tm (referral) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 560.32 56.56 m 590.6 56.56 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 591.04 58.27 Tm (. ) Tj ET EMC /Artifact <> BDC 0.75 w [] 0 d 0.43922 0.68627 0.85098 RG -4.8 419.44 m -4.8 47.23 l S 1 w [] 0 d 0.75 w [] 0 d 157.15 419.44 m 157.15 259.2 l S 1 w [] 0 d 0.25 w [] 0 d 157.15 259.2 m 157.15 258.35 l S 1 w [] 0 d 0.75 w [] 0 d 157.15 257.6 m 157.15 47.22 l S 1 w [] 0 d 0.75 w [] 0 d 251.65 401.99 m 251.65 350.23 l S 1 w [] 0 d 0.75 w [] 0 d 251.65 257.6 m 251.65 199.87 l S 1 w [] 0 d 0.75 w [] 0 d 346.15 419.44 m 346.15 259.2 l S 1 w [] 0 d 0.25 w [] 0 d 346.15 259.2 m 346.15 258.35 l S 1 w [] 0 d 0.75 w [] 0 d 346.15 257.6 m 346.15 47.22 l S 1 w [] 0 d 0.75 w [] 0 d 760.05 419.44 m 760.05 47.23 l S 1 w [] 0 d 0.5 w [] 0 d -4.93 419.69 m 156.52 419.69 l S 1 w [] 0 d 0.5 w [] 0 d 157.02 419.69 m 345.52 419.69 l S 1 w [] 0 d 0.5 w [] 0 d 346.02 419.69 m 760.17 419.69 l S 1 w [] 0 d 0.75 w [] 0 d 157.9 402.36 m 345.4 402.36 l S 1 w [] 0 d 0.75 w [] 0 d -4.05 385.04 m 759.3 385.04 l S 1 w [] 0 d 0.25 w [] 0 d -4.3 350.1 m 156.65 350.1 l S 1 w [] 0 d 0.25 w [] 0 d 157.65 350.1 m 251.15 350.1 l S 1 w [] 0 d 0.25 w [] 0 d 251.4 350.1 m 345.65 350.1 l S 1 w [] 0 d 0.25 w [] 0 d 346.65 350.1 m 759.55 350.1 l S 1 w [] 0 d 0.25 w [] 0 d -4.3 292.12 m 156.65 292.12 l S 1 w [] 0 d 0.25 w [] 0 d 157.65 292.12 m 345.65 292.12 l S 1 w [] 0 d 0.25 w [] 0 d 346.65 292.12 m 759.55 292.12 l S 1 w [] 0 d 0.75 w [] 0 d -4.05 257.97 m 759.3 257.97 l S 1 w [] 0 d 0.75 w [] 0 d -4.05 199.5 m 759.3 199.5 l S 1 w [] 0 d 0.75 w [] 0 d -4.05 154.54 m 759.3 154.54 l S 1 w [] 0 d 0.75 w [] 0 d -4.05 78.04 m 759.3 78.04 l S 1 w [] 0 d 0.75 w [] 0 d -4.8 46.85 m 760.05 46.85 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 16 0 obj <>/Font<>>>>> endobj 17 0 obj <>stream q 0 0 792 612 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 18 18 cm 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 720.57 3.83 Tm (2) Tj ET BT /F5 12 Tf 1 0 0 1 726.05 3.83 Tm ( of) Tj ET BT /F4 12 Tf 1 0 0 1 736.99 3.83 Tm ( ) Tj ET BT /F4 12 Tf 1 0 0 1 739.73 3.83 Tm (8 ) Tj ET Q q Q EMC q 1 0 0 1 18 33.02 cm /Artifact <> BDC 0.93725 0.97647 1 RG 0 J 25.1 w -4.55 554.18 m 37.5 554.18 l S 1 w 25.1 w 37.5 554.18 m 759.95 554.18 l S 1 w EMC q 1 0 0 1 -3.9 541.63 cm q n 0 0 m 34.35 0 l 34.35 25.1 l 0 25.1 l h W n /Figure <>BDC q 34.35 0 0 25.1 0 0 cm /img12338 Do Q EMC Q Q q Q /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 42.9 549.93 Tm (All ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 56.57 549.93 Tm (copayment) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG 57.01 548.22 m 108.08 548.22 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 108.52 549.93 Tm ( and ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 130.41 549.93 Tm (coinsurance) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 130.85 548.22 m 187.94 548.22 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 188.38 549.93 Tm ( costs shown in this chart are after your ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 362.34 549.93 Tm (deductible) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 362.77 548.22 m 411.11 548.22 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 411.55 549.93 Tm ( has been met, if a ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 495.26 549.93 Tm (deductible) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 495.7 548.22 m 544.03 548.22 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 544.47 549.93 Tm ( applies. ) Tj ET EMC /Artifact <> BDC 0.5 w [] 0 d 0.75294 0.9098 0.98431 RG -4.8 566.73 m -4.8 541.63 l S 1 w [] 0 d 0.5 w [] 0 d 760.2 566.73 m 760.2 541.63 l S 1 w [] 0 d 0.5 w [] 0 d -4.8 566.98 m 760.2 566.98 l S 1 w [] 0 d 0.5 w [] 0 d -4.8 541.38 m 760.2 541.38 l S 1 w [] 0 d EMC /Artifact <> BDC 0.02745 0.45882 0.65882 RG 0 J 43.73 w -4.5 513.63 m 129.75 513.63 l S 1 w 43.73 w 130.5 513.63 m 246.75 513.63 l S 1 w 15.29 w 247.5 527.85 m 534.75 527.85 l S 1 w 43.73 w 535.5 513.63 m 759.75 513.63 l S 1 w 27.68 w 247.5 505.61 m 386.25 505.61 l S 1 w 27.68 w 387 505.61 m 534.75 505.61 l S 1 w 0.75294 0.9098 0.98431 RG 121.59 w -4.5 430.22 m 129.75 430.22 l S 1 w 0.93725 0.97647 1 RG 44.21 w 130.5 468.91 m 246.75 468.91 l S 1 w 44.21 w 247.5 468.91 m 386.25 468.91 l S 1 w 44.21 w 387 468.91 m 534.75 468.91 l S 1 w 44.21 w 535.5 468.91 m 759.75 468.91 l S 1 w 1 1 1 RG 17.9 w 130.5 437.11 m 246.75 437.11 l S 1 w 17.9 w 247.5 437.11 m 386.25 437.11 l S 1 w 17.9 w 387 437.11 m 534.75 437.11 l S 1 w 17.9 w 535.5 437.11 m 759.75 437.11 l S 1 w 0.93725 0.97647 1 RG 57.98 w 130.5 398.42 m 246.75 398.42 l S 1 w 57.98 w 247.5 398.42 m 386.25 398.42 l S 1 w 57.98 w 387 398.42 m 534.75 398.42 l S 1 w 57.98 w 535.5 398.42 m 759.75 398.42 l S 1 w 0.75294 0.9098 0.98431 RG 61.63 w -4.5 336.37 m 129.75 336.37 l S 1 w 0.93725 0.97647 1 RG 30.44 w 130.5 320.77 m 246.75 320.77 l S 1 w 30.44 w 247.5 320.77 m 386.25 320.77 l S 1 w 30.44 w 387 320.77 m 534.75 320.77 l S 1 w 30.44 w 535.5 320.77 m 759.75 320.77 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F4 12 Tf 1 0 0 1 -3.43 509.75 Tm (Common Medical Event ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 131.57 509.75 Tm (Services You May Need ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 348.2 523.97 Tm (What You Will Pay ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 547.56 515.95 Tm (Limitations, Exceptions, & Other Important ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 620.57 503.56 Tm (Information ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 270.13 507.93 Tm (In-Network Provider ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 263.83 495.54 Tm (\(You will pay the least\) ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 403.75 507.93 Tm (Out-of-Network Provider ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 407.29 495.54 Tm (\(You will pay the most\) ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -3.43 432.8 Tm (If you visit a health care ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 419.03 Tm (providers) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG -2.99 417.32 m 43.71 417.32 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 44.15 419.03 Tm ( office or clinic ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 471.62 Tm (Primary care visit to treat ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 457.85 Tm (an injury or ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 182.99 457.85 Tm (illness ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 464.73 Tm ($25 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 267.73 464.73 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 268.17 463.02 m 293.55 463.02 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 293.99 464.73 Tm (/office visit ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 464.73 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 464.73 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 463.02 m 463.13 463.02 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 478.5 Tm (Members 18 years and older have access to ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 464.73 Tm (Virtual Primary Care visits by a BCBSM selected ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 450.97 Tm (vendor. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 432.93 Tm (Specialist) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 431.22 m 173.25 431.22 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 173.69 432.93 Tm ( visit ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 432.93 Tm ($50 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 267.73 432.93 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 268.17 431.22 m 293.55 431.22 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 293.99 432.93 Tm (/office visit ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 432.93 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 432.93 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 431.22 m 463.13 431.22 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 432.93 Tm (None ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 408.01 Tm (Preventive care) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 406.3 m 199.51 406.3 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 199.95 408.01 Tm (/ ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 394.24 Tm (screening) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 392.53 m 173.8 392.53 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 174.24 394.24 Tm (/ ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 380.47 Tm (immunization ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 401.13 Tm (No Charge; ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 301.63 401.13 Tm (deductible) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 302.07 399.42 m 346.05 399.42 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 346.49 401.13 Tm ( does ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 387.36 Tm (not apply ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 394.24 Tm (Not covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 414.9 Tm (You may have to pay for services that aren't ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 401.13 Tm (preventive) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 537.01 399.42 m 581.54 399.42 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 581.98 401.13 Tm (. Ask your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 628.47 401.13 Tm (provider) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 628.91 399.42 m 663.58 399.42 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 664.02 401.13 Tm ( if the services ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 387.36 Tm (needed are ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 589.1 387.36 Tm (preventive) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 589.54 385.64 m 634.07 385.64 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 634.51 387.36 Tm (. Then check what your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 738.99 387.36 Tm (plan ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 739.43 385.64 m 757.16 385.64 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 373.59 Tm (will pay for. ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 332.06 Tm (If you have a test ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 354.67 Tm (Diagnostic test) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 352.95 m 195.68 352.95 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 196.12 354.67 Tm ( \(x-ray, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 340.9 Tm (blood work\) ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 347.78 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 347.78 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 346.07 m 323.63 346.07 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 347.78 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 347.78 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 346.07 m 463.13 346.07 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 347.78 Tm (None ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 323.48 Tm (Imaging \(CT/PET scans, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 309.71 Tm (MRIs\) ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 316.59 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 316.59 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 314.88 m 323.63 314.88 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 316.59 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 316.59 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 314.88 m 463.13 314.88 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 316.59 Tm (May require ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 591.27 316.59 Tm (prior authorization. ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 591.71 314.88 m 672.33 314.88 l S 1 w [] 0 d EMC /Artifact <> BDC 0.75 w [] 0 d 0.43922 0.68627 0.85098 RG -4.88 535.49 m -4.88 305.55 l S 1 w [] 0 d 0.75 w [] 0 d 130.13 535.49 m 130.13 369.43 l S 1 w [] 0 d 0.75 w [] 0 d 130.13 367.18 m 130.13 305.55 l S 1 w [] 0 d 0.75 w [] 0 d 247.13 535.49 m 247.13 369.43 l S 1 w [] 0 d 0.75 w [] 0 d 247.13 367.18 m 247.13 305.55 l S 1 w [] 0 d 0.75 w [] 0 d 386.63 519.45 m 386.63 369.43 l S 1 w [] 0 d 0.75 w [] 0 d 386.63 367.18 m 386.63 305.55 l S 1 w [] 0 d 0.75 w [] 0 d 535.13 535.49 m 535.13 369.43 l S 1 w [] 0 d 0.75 w [] 0 d 535.13 367.18 m 535.13 305.55 l S 1 w [] 0 d 0.75 w [] 0 d 760.13 535.49 m 760.13 305.55 l S 1 w [] 0 d 0.75 w [] 0 d -4.88 535.87 m 760.13 535.87 l S 1 w [] 0 d 0.75 w [] 0 d 247.88 519.83 m 534.38 519.83 l S 1 w [] 0 d 0.75 w [] 0 d -4.13 491.39 m 759.38 491.39 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 446.43 m 759.38 446.43 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 427.78 m 759.38 427.78 l S 1 w [] 0 d 0 J 2.25 w [] 0 d -4.5 368.3 m 759.75 368.3 l S 1 w [] 0 d 2 J 0.75 w [] 0 d 130.88 336.36 m 759.38 336.36 l S 1 w [] 0 d 0 J 2.25 w [] 0 d -5.25 304.43 m 760.5 304.43 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 18 0 obj <>>>>> endobj 19 0 obj <>/Border[ 0 0 0]/StructParent 4/Rect[ 14.57 366.88 128.31 380.65]/Contents(www.bcbsm.com forward slash drug lists)/Subtype/Link>> endobj 21 0 obj <>stream q 0 0 792 612 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 18 18 cm 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 720.57 3.83 Tm (3) Tj ET BT /F5 12 Tf 1 0 0 1 726.05 3.83 Tm ( of) Tj ET BT /F4 12 Tf 1 0 0 1 736.99 3.83 Tm ( ) Tj ET BT /F4 12 Tf 1 0 0 1 739.73 3.83 Tm (8 ) Tj ET Q q Q EMC q 1 0 0 1 18 33.02 cm /Artifact <> BDC 0.02745 0.45882 0.65882 RG 0 J 43.73 w -4.5 544.61 m 129.75 544.61 l S 1 w 43.73 w 130.5 544.61 m 246.75 544.61 l S 1 w 15.29 w 247.5 558.83 m 534.75 558.83 l S 1 w 43.73 w 535.5 544.61 m 759.75 544.61 l S 1 w 27.68 w 247.5 536.59 m 386.25 536.59 l S 1 w 27.68 w 387 536.59 m 534.75 536.59 l S 1 w 0.75294 0.9098 0.98431 RG 307.05 w -4.5 368.85 m 129.75 368.85 l S 1 w 1 1 1 RG 56.2 w 130.5 494.27 m 246.75 494.27 l S 1 w 56.2 w 247.5 494.27 m 386.25 494.27 l S 1 w 56.2 w 387 494.27 m 534.75 494.27 l S 1 w 0.93725 0.97647 1 RG 167.86 w 535.5 438.45 m 759.75 438.45 l S 1 w 55.08 w 130.5 437.88 m 246.75 437.88 l S 1 w 55.08 w 247.5 437.88 m 386.25 437.88 l S 1 w 55.08 w 387 437.88 m 534.75 437.88 l S 1 w 1 1 1 RG 55.08 w 130.5 382.05 m 246.75 382.05 l S 1 w 55.08 w 247.5 382.05 m 386.25 382.05 l S 1 w 55.08 w 387 382.05 m 534.75 382.05 l S 1 w 0.93725 0.97647 1 RG 68.85 w 130.5 319.34 m 246.75 319.34 l S 1 w 68.85 w 247.5 319.34 m 386.25 319.34 l S 1 w 68.85 w 387 319.34 m 534.75 319.34 l S 1 w 1 1 1 RG 138.45 w 535.5 284.54 m 759.75 284.54 l S 1 w 69.22 w 130.5 249.93 m 246.75 249.93 l S 1 w 69.22 w 247.5 249.93 m 386.25 249.93 l S 1 w 69.22 w 387 249.93 m 534.75 249.93 l S 1 w 0.75294 0.9098 0.98431 RG 61.63 w -4.5 182.26 m 129.75 182.26 l S 1 w 0.93725 0.97647 1 RG 44.21 w 130.5 190.97 m 246.75 190.97 l S 1 w 44.21 w 247.5 190.97 m 386.25 190.97 l S 1 w 44.21 w 387 190.97 m 534.75 190.97 l S 1 w 44.21 w 535.5 190.97 m 759.75 190.97 l S 1 w 1 1 1 RG 16.67 w 130.5 159.78 m 246.75 159.78 l S 1 w 16.67 w 247.5 159.78 m 386.25 159.78 l S 1 w 16.67 w 387 159.78 m 534.75 159.78 l S 1 w 16.67 w 535.5 159.78 m 759.75 159.78 l S 1 w 0.75294 0.9098 0.98431 RG 80.28 w -4.5 109.05 m 129.75 109.05 l S 1 w 0.93725 0.97647 1 RG 30.44 w 130.5 133.97 m 246.75 133.97 l S 1 w 30.44 w 247.5 133.97 m 386.25 133.97 l S 1 w 30.44 w 387 133.97 m 534.75 133.97 l S 1 w 30.44 w 535.5 133.97 m 759.75 133.97 l S 1 w 1 1 1 RG 30.44 w 130.5 102.78 m 246.75 102.78 l S 1 w 30.44 w 247.5 102.78 m 386.25 102.78 l S 1 w 30.44 w 387 102.78 m 534.75 102.78 l S 1 w 30.44 w 535.5 102.78 m 759.75 102.78 l S 1 w 0.93725 0.97647 1 RG 17.9 w 130.5 77.86 m 246.75 77.86 l S 1 w 17.9 w 247.5 77.86 m 386.25 77.86 l S 1 w 17.9 w 387 77.86 m 534.75 77.86 l S 1 w 17.9 w 535.5 77.86 m 759.75 77.86 l S 1 w 0.75294 0.9098 0.98431 RG 49.09 w -4.5 42.12 m 129.75 42.12 l S 1 w 1 1 1 RG 30.44 w 130.5 51.44 m 246.75 51.44 l S 1 w 30.44 w 247.5 51.44 m 386.25 51.44 l S 1 w 30.44 w 387 51.44 m 534.75 51.44 l S 1 w 30.44 w 535.5 51.44 m 759.75 51.44 l S 1 w 0.93725 0.97647 1 RG 17.9 w 130.5 26.52 m 246.75 26.52 l S 1 w 17.9 w 247.5 26.52 m 386.25 26.52 l S 1 w 17.9 w 387 26.52 m 534.75 26.52 l S 1 w 17.9 w 535.5 26.52 m 759.75 26.52 l S 1 w EMC /Artifact <> BDC 1 1 1 rg BT /F4 12 Tf 1 0 0 1 -3.43 540.74 Tm (Common Medical Event ) Tj ET BT /F4 12 Tf 1 0 0 1 131.57 540.74 Tm (Services You May Need ) Tj ET BT /F4 12 Tf 1 0 0 1 348.2 554.96 Tm (What You Will Pay ) Tj ET BT /F4 12 Tf 1 0 0 1 547.56 546.93 Tm (Limitations, Exceptions, & Other Important ) Tj ET BT /F4 12 Tf 1 0 0 1 620.57 534.54 Tm (Information ) Tj ET BT /F4 12 Tf 1 0 0 1 270.13 538.91 Tm (In-Network Provider ) Tj ET BT /F4 12 Tf 1 0 0 1 263.83 526.52 Tm (\(You will pay the least\) ) Tj ET BT /F4 12 Tf 1 0 0 1 403.75 538.91 Tm (Out-of-Network Provider ) Tj ET BT /F4 12 Tf 1 0 0 1 407.29 526.52 Tm (\(You will pay the most\) ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -3.43 405.29 Tm (If you need drugs to treat ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 391.52 Tm (your illness or condition ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 -3.43 377.88 Tm (More information about ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 363.98 Tm (prescription drug coverage ) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG -2.99 362.27 m 123.55 362.27 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 -3.43 350.34 Tm (is available at ) Tj ET EMC /Span <>BDC 0 0 1 rg BT /F5 12 Tf 1 0 0 1 -3.43 336.57 Tm (www.bcbsm.com/druglists ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 1 RG -2.99 334.86 m 109.87 334.86 l S 1 w [] 0 d EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 131.57 489.53 Tm (Generic drugs ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 510.19 Tm ($10 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 267.73 510.19 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 0 RG 268.17 508.48 m 293.55 508.48 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 293.99 510.19 Tm (/prescription for ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 496.42 Tm (retail 34-day supply; $30 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 482.65 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 249.01 480.94 m 274.4 480.94 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 274.84 482.65 Tm (/prescription for retail or ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 468.88 Tm (mail order 30-day supply ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 503.3 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 438.38 503.3 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 438.82 501.59 m 464.2 501.59 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 464.64 503.3 Tm ( plus an ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 489.53 Tm (additional 25% of the approved ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 475.76 Tm (amount ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 468.13 Tm (Prior authorization) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 537.01 466.42 m 615.99 466.42 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 616.43 468.13 Tm (, step therapy and quantity limits ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 454.36 Tm (may apply to select drugs. Preventive drugs ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 440.59 Tm (covered in full. A 90-day supply of prescription ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 426.82 Tm (drugs is not payable at a retail pharmacy. A 90- ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 413.05 Tm (day supply is only payable at a participating mail ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 399.28 Tm (order pharmacy. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 440.59 Tm (Preferred brand-name ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 426.82 Tm (drugs ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 454.36 Tm ($40 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 267.73 454.36 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 268.17 452.65 m 293.55 452.65 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 293.99 454.36 Tm (/prescription for ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 440.59 Tm (retail 34-day supply; $120 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 426.82 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 249.01 425.11 m 274.4 425.11 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 274.84 426.82 Tm (/prescription for retail or ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 413.05 Tm (mail order 30-day supply ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 447.47 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 438.38 447.47 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 438.82 445.76 m 464.2 445.76 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 464.64 447.47 Tm ( plus an ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 433.7 Tm (additional 25% of the approved ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 419.94 Tm (amount ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 384.76 Tm (Non-preferred brand- ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 370.99 Tm (name drugs ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 398.53 Tm ($80 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 267.73 398.53 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 268.17 396.82 m 293.55 396.82 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 293.99 398.53 Tm (/prescription for ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 384.76 Tm (retail 34-day supply; $240 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 370.99 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 249.01 369.28 m 274.4 369.28 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 274.84 370.99 Tm (/prescription for retail or ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 357.22 Tm (mail order 30-day supply ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 391.65 Tm (In-Network ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 438.38 391.65 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 438.82 389.93 m 464.2 389.93 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 464.64 391.65 Tm ( plus an ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 377.88 Tm (additional 25% of the approved ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 364.11 Tm (amount ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 328.93 Tm (Generic and preferred ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 315.16 Tm (brand-name specialty ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 301.39 Tm (Drugs ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 342.7 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 342.7 Tm (coinsurance) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 340.99 m 323.63 340.99 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 324.07 342.7 Tm ( of the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 328.93 Tm (approved amount, but no more ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 315.16 Tm (than $150 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 295.09 315.16 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 295.53 313.45 m 320.91 313.45 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 321.35 315.16 Tm (/prescription ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 301.39 Tm (for specialty pharmacy 30-day ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 287.62 Tm (supply ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 315.16 Tm (Not covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 294.13 Tm (Prior authorization) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 537.01 292.42 m 615.99 292.42 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 616.43 294.13 Tm (is required. Specialty drugs ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 280.36 Tm (limited to a 15 or 30-day supply. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 252.45 Tm (Nonpreferred brand-name ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 238.68 Tm (specialty drugs ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 273.11 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 273.11 Tm (coinsurance) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 271.39 m 323.63 271.39 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 324.07 273.11 Tm ( of the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 259.33 Tm (approved amount, but no more ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 245.57 Tm (than $300 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 295.09 245.57 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 295.53 243.85 m 320.91 243.85 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 321.35 245.57 Tm (/prescription ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 231.8 Tm (for specialty pharmacy 30-day ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 218.03 Tm (supply ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 245.57 Tm (Not covered ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 184.83 Tm (If you have outpatient ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 171.06 Tm (surgery ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 200.56 Tm (Facility fee \(e.g., ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 186.79 Tm (ambulatory surgery ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 173.02 Tm (center\) ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 186.79 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 186.79 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 185.08 m 323.63 185.08 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 186.79 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 186.79 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 185.08 m 463.13 185.08 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 186.79 Tm (None ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 155.6 Tm (Physician/surgeon fees ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 155.6 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 155.6 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 153.89 m 323.63 153.89 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 155.6 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 155.6 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 153.89 m 463.13 153.89 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 155.6 Tm (None ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 111.63 Tm (If you need immediate ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 97.86 Tm (medical attention ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 129.79 Tm (Emergency room care ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 128.08 m 227.94 128.08 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 129.79 Tm ($200 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 273.2 129.79 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 273.64 128.08 m 299.02 128.08 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 299.46 129.79 Tm (/visit ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 129.79 Tm ($200 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 412.7 129.79 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 413.14 128.08 m 438.52 128.08 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 438.96 129.79 Tm (/visit ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 136.68 Tm (Copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 537.01 134.97 m 564.58 134.97 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 565.02 136.68 Tm ( waived if admitted or for an accidental ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 122.91 Tm (injury. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 105.49 Tm (Emergency medical ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 103.78 m 217.55 103.78 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 91.72 Tm (transportation ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 90.01 m 191.31 90.01 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 98.61 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 98.61 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 96.89 m 323.63 96.89 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 98.61 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 98.61 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 96.89 m 463.13 96.89 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 98.61 Tm (Mileage limits apply ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 73.69 Tm (Urgent care ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 71.97 m 182.54 71.97 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 73.69 Tm ($50 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 267.73 73.69 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 268.17 71.97 m 293.55 71.97 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 293.99 73.69 Tm (/visit ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 73.69 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 73.69 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 71.97 m 463.13 71.97 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 73.69 Tm (None ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 37.81 Tm (If you have a hospital stay ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 54.15 Tm (Facility fee \(e.g., hospital ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 40.38 Tm (room\) ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 47.27 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 47.27 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 45.56 m 323.63 45.56 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 47.27 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 47.27 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 45.56 m 463.13 45.56 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 47.27 Tm (Prior authorization) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 537.01 45.56 m 615.99 45.56 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 616.43 47.27 Tm ( is required. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 22.35 Tm (Physician/surgeon fee ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 22.35 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 22.35 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 20.64 m 323.63 20.64 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 22.35 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 22.35 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 20.64 m 463.13 20.64 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 22.35 Tm (None ) Tj ET EMC /Artifact <> BDC 0.75 w [] 0 d 0.43922 0.68627 0.85098 RG -4.88 566.48 m -4.88 17.57 l S 1 w [] 0 d 0.75 w [] 0 d 130.13 566.48 m 130.13 215.32 l S 1 w [] 0 d 0.75 w [] 0 d 130.13 213.07 m 130.13 151.44 l S 1 w [] 0 d 0.75 w [] 0 d 130.13 149.19 m 130.13 68.91 l S 1 w [] 0 d 0.75 w [] 0 d 130.13 66.66 m 130.13 17.57 l S 1 w [] 0 d 0.75 w [] 0 d 247.13 566.48 m 247.13 215.32 l S 1 w [] 0 d 0.75 w [] 0 d 247.13 213.07 m 247.13 151.44 l S 1 w [] 0 d 0.75 w [] 0 d 247.13 149.19 m 247.13 68.91 l S 1 w [] 0 d 0.75 w [] 0 d 247.13 66.66 m 247.13 17.57 l S 1 w [] 0 d 0.75 w [] 0 d 386.63 550.43 m 386.63 215.32 l S 1 w [] 0 d 0.75 w [] 0 d 386.63 213.07 m 386.63 151.44 l S 1 w [] 0 d 0.75 w [] 0 d 386.63 149.19 m 386.63 68.91 l S 1 w [] 0 d 0.75 w [] 0 d 386.63 66.66 m 386.63 17.57 l S 1 w [] 0 d 0.75 w [] 0 d 535.13 566.48 m 535.13 215.32 l S 1 w [] 0 d 0.75 w [] 0 d 535.13 213.07 m 535.13 151.44 l S 1 w [] 0 d 0.75 w [] 0 d 535.13 149.19 m 535.13 68.91 l S 1 w [] 0 d 0.75 w [] 0 d 535.13 66.66 m 535.13 17.57 l S 1 w [] 0 d 0.75 w [] 0 d 760.13 566.48 m 760.13 17.57 l S 1 w [] 0 d 0.75 w [] 0 d -4.88 566.85 m 760.13 566.85 l S 1 w [] 0 d 0.75 w [] 0 d 247.88 550.81 m 534.38 550.81 l S 1 w [] 0 d 0.75 w [] 0 d -4.13 522.37 m 759.38 522.37 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 465.8 m 534.38 465.8 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 409.97 m 534.38 409.97 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 354.14 m 759.38 354.14 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 284.54 m 534.38 284.54 l S 1 w [] 0 d 0 J 2.25 w [] 0 d -4.5 214.2 m 759.75 214.2 l S 1 w [] 0 d 2 J 0.75 w [] 0 d 130.88 168.49 m 759.38 168.49 l S 1 w [] 0 d 0 J 2.25 w [] 0 d -4.5 150.32 m 759.75 150.32 l S 1 w [] 0 d 2 J 0.75 w [] 0 d 130.88 118.38 m 759.38 118.38 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 87.19 m 759.38 87.19 l S 1 w [] 0 d 0 J 2.25 w [] 0 d -4.5 67.79 m 759.75 67.79 l S 1 w [] 0 d 2 J 0.75 w [] 0 d 130.88 35.85 m 759.38 35.85 l S 1 w [] 0 d 0 J 2.25 w [] 0 d -5.25 16.45 m 760.5 16.45 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 22 0 obj <>>>>> endobj 23 0 obj <>stream q 0 0 792 612 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 18 18 cm 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 720.57 3.83 Tm (4) Tj ET BT /F5 12 Tf 1 0 0 1 726.05 3.83 Tm ( of) Tj ET BT /F4 12 Tf 1 0 0 1 736.99 3.83 Tm ( ) Tj ET BT /F4 12 Tf 1 0 0 1 739.73 3.83 Tm (8 ) Tj ET Q q Q EMC q 1 0 0 1 18 33.02 cm /Artifact <> BDC 0.02745 0.45882 0.65882 RG 0 J 43.73 w -4.5 544.61 m 129.75 544.61 l S 1 w 43.73 w 130.5 544.61 m 246.75 544.61 l S 1 w 15.29 w 247.5 558.83 m 534.75 558.83 l S 1 w 43.73 w 535.5 544.61 m 759.75 544.61 l S 1 w 27.68 w 247.5 536.59 m 386.25 536.59 l S 1 w 27.68 w 387 536.59 m 534.75 536.59 l S 1 w 0.75294 0.9098 0.98431 RG 57.98 w -4.5 492.26 m 129.75 492.26 l S 1 w 1 1 1 RG 17.9 w 130.5 512.3 m 246.75 512.3 l S 1 w 17.9 w 247.5 512.3 m 386.25 512.3 l S 1 w 17.9 w 387 512.3 m 534.75 512.3 l S 1 w 17.9 w 535.5 512.3 m 759.75 512.3 l S 1 w 0.93725 0.97647 1 RG 39.33 w 130.5 482.93 m 246.75 482.93 l S 1 w 39.33 w 247.5 482.93 m 386.25 482.93 l S 1 w 39.33 w 387 482.93 m 534.75 482.93 l S 1 w 39.33 w 535.5 482.93 m 759.75 482.93 l S 1 w 0.75294 0.9098 0.98431 RG 134.13 w -4.5 394.71 m 129.75 394.71 l S 1 w 1 1 1 RG 71.75 w 130.5 425.9 m 246.75 425.9 l S 1 w 71.75 w 247.5 425.9 m 386.25 425.9 l S 1 w 71.75 w 387 425.9 m 534.75 425.9 l S 1 w 71.75 w 535.5 425.9 m 759.75 425.9 l S 1 w 0.93725 0.97647 1 RG 30.44 w 130.5 374.05 m 246.75 374.05 l S 1 w 30.44 w 247.5 374.05 m 386.25 374.05 l S 1 w 30.44 w 387 374.05 m 534.75 374.05 l S 1 w 30.44 w 535.5 374.05 m 759.75 374.05 l S 1 w 1 1 1 RG 30.44 w 130.5 342.86 m 246.75 342.86 l S 1 w 30.44 w 247.5 342.86 m 386.25 342.86 l S 1 w 30.44 w 387 342.86 m 534.75 342.86 l S 1 w 30.44 w 535.5 342.86 m 759.75 342.86 l S 1 w 0.75294 0.9098 0.98431 RG 215.15 w -4.5 217.82 m 129.75 217.82 l S 1 w 0.93725 0.97647 1 RG 17.9 w 130.5 316.45 m 246.75 316.45 l S 1 w 17.9 w 247.5 316.45 m 386.25 316.45 l S 1 w 17.9 w 387 316.45 m 534.75 316.45 l S 1 w 17.9 w 535.5 316.45 m 759.75 316.45 l S 1 w 1 1 1 RG 44.21 w 130.5 284.64 m 246.75 284.64 l S 1 w 44.21 w 247.5 284.64 m 386.25 284.64 l S 1 w 44.21 w 387 284.64 m 534.75 284.64 l S 1 w 44.21 w 535.5 284.64 m 759.75 284.64 l S 1 w 0.93725 0.97647 1 RG 57.98 w 130.5 232.8 m 246.75 232.8 l S 1 w 57.98 w 247.5 232.8 m 386.25 232.8 l S 1 w 57.98 w 387 232.8 m 534.75 232.8 l S 1 w 57.98 w 535.5 232.8 m 759.75 232.8 l S 1 w 1 1 1 RG 30.44 w 130.5 187.84 m 246.75 187.84 l S 1 w 30.44 w 247.5 187.84 m 386.25 187.84 l S 1 w 30.44 w 387 187.84 m 534.75 187.84 l S 1 w 30.44 w 535.5 187.84 m 759.75 187.84 l S 1 w 0.93725 0.97647 1 RG 44.21 w 130.5 149.77 m 246.75 149.77 l S 1 w 44.21 w 247.5 149.77 m 386.25 149.77 l S 1 w 44.21 w 387 149.77 m 534.75 149.77 l S 1 w 44.21 w 535.5 149.77 m 759.75 149.77 l S 1 w 1 1 1 RG 16.67 w 130.5 118.58 m 246.75 118.58 l S 1 w 16.67 w 247.5 118.58 m 386.25 118.58 l S 1 w 16.67 w 387 118.58 m 534.75 118.58 l S 1 w 16.67 w 535.5 118.58 m 759.75 118.58 l S 1 w 0.75294 0.9098 0.98431 RG 98.94 w -4.5 58.52 m 129.75 58.52 l S 1 w 0.93725 0.97647 1 RG 17.9 w 130.5 99.04 m 246.75 99.04 l S 1 w 17.9 w 247.5 99.04 m 386.25 99.04 l S 1 w 17.9 w 387 99.04 m 534.75 99.04 l S 1 w 17.9 w 535.5 99.04 m 759.75 99.04 l S 1 w 1 1 1 RG 17.9 w 130.5 80.39 m 246.75 80.39 l S 1 w 17.9 w 247.5 80.39 m 386.25 80.39 l S 1 w 17.9 w 387 80.39 m 534.75 80.39 l S 1 w 17.9 w 535.5 80.39 m 759.75 80.39 l S 1 w 0.93725 0.97647 1 RG 61.65 w 130.5 39.87 m 246.75 39.87 l S 1 w 61.65 w 247.5 39.87 m 386.25 39.87 l S 1 w 61.65 w 387 39.87 m 534.75 39.87 l S 1 w 61.65 w 535.5 39.87 m 759.75 39.87 l S 1 w EMC /Artifact <> BDC 1 1 1 rg BT /F4 12 Tf 1 0 0 1 -3.43 540.74 Tm (Common Medical Event ) Tj ET BT /F4 12 Tf 1 0 0 1 131.57 540.74 Tm (Services You May Need ) Tj ET BT /F4 12 Tf 1 0 0 1 348.2 554.96 Tm (What You Will Pay ) Tj ET BT /F4 12 Tf 1 0 0 1 547.56 546.93 Tm (Limitations, Exceptions, & Other Important ) Tj ET BT /F4 12 Tf 1 0 0 1 620.57 534.54 Tm (Information ) Tj ET BT /F4 12 Tf 1 0 0 1 270.13 538.91 Tm (In-Network Provider ) Tj ET BT /F4 12 Tf 1 0 0 1 263.83 526.52 Tm (\(You will pay the least\) ) Tj ET BT /F4 12 Tf 1 0 0 1 403.75 538.91 Tm (Out-of-Network Provider ) Tj ET BT /F4 12 Tf 1 0 0 1 407.29 526.52 Tm (\(You will pay the most\) ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 -3.43 508.61 Tm (If you need behavioral ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 494.84 Tm (health services \(mental ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 481.07 Tm (health and substance use ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 467.3 Tm (disorder\) ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 508.12 Tm (Outpatient) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 176.99 508.12 Tm ( services ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 508.12 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 508.12 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG 271.44 506.41 m 323.63 506.41 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 508.12 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 508.12 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 506.41 m 463.13 506.41 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 508.12 Tm (None ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 478.76 Tm (Inpatient services ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 478.76 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 478.76 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 477.05 m 323.63 477.05 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 478.76 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 478.76 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 477.05 m 463.13 477.05 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 478.76 Tm (Prior authorization) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 537.01 477.05 m 615.99 477.05 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 616.43 478.76 Tm ( is required. ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 390.4 Tm (If you are pregnant ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 421.72 Tm (Office visits ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 428.6 Tm (No Charge; ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 301.63 428.6 Tm (deductible) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 302.07 426.89 m 346.05 426.89 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 346.49 428.6 Tm ( does ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 414.84 Tm (not apply ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 421.72 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 421.72 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 420.01 m 463.13 420.01 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 449.26 Tm (Maternity care may include tests and services ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 435.49 Tm (described elsewhere in the SBC \(i.e. ultrasound\) ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 421.72 Tm (and depending on the type of services ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 705.65 421.72 Tm (cost share ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 706.09 420.01 m 750.61 420.01 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 407.95 Tm (may apply. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 586.9 407.95 Tm (Cost sharing) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 587.34 406.24 m 641.7 406.24 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 642.14 407.95 Tm ( does not apply for ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 394.18 Tm (preventive services) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 537.01 392.47 m 620.37 392.47 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 620.81 394.18 Tm (. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 376.76 Tm (Childbirth/delivery ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 362.99 Tm (professional services ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 369.88 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 369.88 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 368.17 m 323.63 368.17 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 369.88 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 369.88 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 368.17 m 463.13 368.17 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 369.88 Tm (None ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 345.57 Tm (Childbirth/delivery facility ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 331.8 Tm (services ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 338.69 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 338.69 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 336.98 m 323.63 336.98 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 338.69 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 338.69 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 336.98 m 463.13 336.98 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 338.69 Tm (None ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 227.28 Tm (If you need help recovering ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 213.51 Tm (or have other special health ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 199.74 Tm (needs ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 312.27 Tm (Home health care ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 310.56 m 208.81 310.56 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 312.27 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 312.27 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 310.56 m 323.63 310.56 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 312.27 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 312.27 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 310.56 m 463.13 310.56 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 312.27 Tm (Physician certification required. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 280.46 Tm (Rehabilitation services ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 278.75 m 229.59 278.75 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 280.46 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 280.46 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 278.75 m 323.63 278.75 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 280.46 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 280.46 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 278.75 m 463.13 278.75 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 294.23 Tm (Physical, Speech and Occupational Therapy is ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 280.46 Tm (limited to a combined maximum of 60 visits per ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 266.69 Tm (member, per calendar year. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 228.62 Tm (Habilitation services ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 226.91 m 218.65 226.91 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 249.27 Tm ($25 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 267.73 249.27 Tm (copay) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 268.17 247.56 m 293.55 247.56 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 293.99 249.27 Tm (/office visit 20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 235.51 Tm (coinsurance) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 249.01 233.79 m 301.2 233.79 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 301.64 235.51 Tm ( for Physical, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 221.74 Tm (Speech and Occupational ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 207.97 Tm (Therapy ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 228.62 Tm (40% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 228.62 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 226.91 m 463.13 226.91 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 249.27 Tm (Prior authorization is required for applied behavior ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 235.51 Tm (analysis \(ABA\). Services rendered by an approved ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 221.74 Tm (licensed behavior analyst \(LBA\) will apply the In- ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 207.97 Tm (network cost-sharing. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 183.66 Tm (Skilled nursing care ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 181.95 m 217.01 181.95 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 183.66 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 183.66 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 181.95 m 323.63 181.95 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 183.66 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 183.66 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 181.95 m 463.13 181.95 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 190.55 Tm (Physician certification required. Limited to 120 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 176.78 Tm (days per member per calendar year ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 152.47 Tm (Durable medical ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 150.76 m 202.23 150.76 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 138.7 Tm (equipment ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 136.99 m 177.09 136.99 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 145.59 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 145.59 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 143.88 m 323.63 143.88 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 145.59 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 145.59 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 143.88 m 463.13 143.88 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 159.36 Tm (Excludes bath, exercise and deluxe equipment ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 145.59 Tm (and comfort and convenience items. Prescription ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 131.82 Tm (required. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 114.4 Tm (Hospice services ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 132.01 112.69 m 205.51 112.69 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 114.4 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 271.01 114.4 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 271.44 112.69 m 323.63 112.69 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 114.4 Tm (20% ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 410.51 114.4 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 410.94 112.69 m 463.13 112.69 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 114.4 Tm (Physician certification required. Unlimited visits. ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 95.35 Tm (If your child needs dental or ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 -3.43 81.58 Tm (eye care ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 -3.43 67.94 Tm (For more information on ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 -3.43 54.17 Tm (pediatric vision or dental, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 -3.43 40.4 Tm (contact your plan ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 -3.43 26.63 Tm (administrator ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 94.86 Tm (Childrens eye exam ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 94.86 Tm (Not covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 94.86 Tm (Not covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 94.86 Tm (None ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 76.21 Tm (Childrens glasses ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 76.21 Tm (Not covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 76.21 Tm (Not covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 76.21 Tm (None ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 42.58 Tm (Childrens dental check- ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 131.57 28.81 Tm (up ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.58 35.69 Tm (Not covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 388.08 35.69 Tm (Not covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.58 35.69 Tm (None ) Tj ET EMC /Artifact <> BDC 0.75 w [] 0 d 0.43922 0.68627 0.85098 RG -4.88 566.48 m -4.88 9.05 l S 1 w [] 0 d 0.75 w [] 0 d 130.13 566.48 m 130.13 523.5 l S 1 w [] 0 d 0.75 w [] 0 d 130.13 521.25 m 130.13 464.02 l S 1 w [] 0 d 0.75 w [] 0 d 130.13 461.77 m 130.13 327.64 l S 1 w [] 0 d 0.75 w [] 0 d 130.13 325.39 m 130.13 110.24 l S 1 w [] 0 d 0.75 w [] 0 d 130.13 107.99 m 130.13 9.05 l S 1 w [] 0 d 0.75 w [] 0 d 247.13 566.48 m 247.13 523.5 l S 1 w [] 0 d 0.75 w [] 0 d 247.13 521.25 m 247.13 464.02 l S 1 w [] 0 d 0.75 w [] 0 d 247.13 461.77 m 247.13 327.64 l S 1 w [] 0 d 0.75 w [] 0 d 247.13 325.39 m 247.13 110.24 l S 1 w [] 0 d 0.75 w [] 0 d 247.13 107.99 m 247.13 9.05 l S 1 w [] 0 d 0.75 w [] 0 d 386.63 550.43 m 386.63 523.5 l S 1 w [] 0 d 0.75 w [] 0 d 386.63 521.25 m 386.63 464.02 l S 1 w [] 0 d 0.75 w [] 0 d 386.63 461.77 m 386.63 327.64 l S 1 w [] 0 d 0.75 w [] 0 d 386.63 325.39 m 386.63 110.24 l S 1 w [] 0 d 0.75 w [] 0 d 386.63 107.99 m 386.63 9.05 l S 1 w [] 0 d 0.75 w [] 0 d 535.13 566.48 m 535.13 523.5 l S 1 w [] 0 d 0.75 w [] 0 d 535.13 521.25 m 535.13 464.02 l S 1 w [] 0 d 0.75 w [] 0 d 535.13 461.77 m 535.13 327.64 l S 1 w [] 0 d 0.75 w [] 0 d 535.13 325.39 m 535.13 110.24 l S 1 w [] 0 d 0.75 w [] 0 d 535.13 107.99 m 535.13 9.05 l S 1 w [] 0 d 0.75 w [] 0 d 760.13 566.48 m 760.13 9.05 l S 1 w [] 0 d 0.75 w [] 0 d -4.88 566.85 m 760.13 566.85 l S 1 w [] 0 d 0.75 w [] 0 d 247.88 550.81 m 534.38 550.81 l S 1 w [] 0 d 0 J 2.25 w [] 0 d -4.5 522.37 m 759.75 522.37 l S 1 w [] 0 d 2 J 0.75 w [] 0 d 130.88 502.97 m 759.38 502.97 l S 1 w [] 0 d 0 J 2.25 w [] 0 d -4.5 462.89 m 759.75 462.89 l S 1 w [] 0 d 2 J 0.75 w [] 0 d 130.88 389.65 m 759.38 389.65 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 358.46 m 759.38 358.46 l S 1 w [] 0 d 0 J 2.25 w [] 0 d -4.5 326.52 m 759.75 326.52 l S 1 w [] 0 d 2 J 0.75 w [] 0 d 130.88 307.12 m 759.38 307.12 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 262.16 m 759.38 262.16 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 203.43 m 759.38 203.43 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 172.24 m 759.38 172.24 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 127.29 m 759.38 127.29 l S 1 w [] 0 d 0 J 2.25 w [] 0 d -4.5 109.11 m 759.75 109.11 l S 1 w [] 0 d 2 J 0.75 w [] 0 d 130.88 89.72 m 759.38 89.72 l S 1 w [] 0 d 0.75 w [] 0 d 130.88 71.07 m 759.38 71.07 l S 1 w [] 0 d 0 J 2.25 w [] 0 d -5.25 7.92 m 760.5 7.92 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 24 0 obj <>>>>> endobj 27 0 obj <>stream q 0 0 792 612 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 18 18 cm 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 720.57 3.83 Tm (5) Tj ET BT /F5 12 Tf 1 0 0 1 726.05 3.83 Tm ( of) Tj ET BT /F4 12 Tf 1 0 0 1 736.99 3.83 Tm ( ) Tj ET BT /F4 12 Tf 1 0 0 1 739.73 3.83 Tm (8 ) Tj ET Q q Q EMC q 1 0 0 1 18 33.02 cm /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 0 542.61 Tm ( ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 2.74 542.61 Tm (Excluded Services & Other Covered Services: ) Tj ET EMC /Artifact <> BDC 0.93725 0.97647 1 RG 0 J 15 w -3.6 532.03 m 760 532.03 l S 1 w EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 1.55 527.72 Tm (Services Your ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 69.92 527.72 Tm (Plan) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG 70.36 526.01 m 90.26 526.01 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 90.71 527.72 Tm ( Generally ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 141.04 527.72 Tm (Does NOT Cover \() Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 225.24 527.72 Tm (Check your policy or ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 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Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 307.83 437.41 Tm ( This isnt a complete list. Please see your ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 507.48 437.41 Tm (plan) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG 507.92 435.7 m 527.28 435.7 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 527.72 437.41 Tm ( document.) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 580.2 437.41 Tm (\) ) Tj ET EMC /Span <>BDC BT /F26 12 Tf 1 0 0 1 1.55 415.4 Tm (x) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 19.55 415.4 Tm (Chiropractic care ) Tj ET EMC /Span <>BDC BT /F26 12 Tf 1 0 0 1 1.55 394.63 Tm (x) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 19.55 394.63 Tm (Coverage provided outside the United States. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 19.55 380.86 Tm (See \() Tj ET EMC /Span <>BDC 0 0 1 rg BT /F5 12 Tf 1 0 0 1 43.07 380.86 Tm (http://www.messa.org) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 1 RG 43.51 379.15 m 137.24 379.15 l S 1 w [] 0 d EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 137.68 380.86 Tm (\) ) Tj ET EMC /Span <>BDC BT /F26 12 Tf 1 0 0 1 244.55 415.4 Tm (x) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 262.55 415.4 Tm (Infertility treatment ) Tj ET EMC /Span <>BDC BT /F26 12 Tf 1 0 0 1 244.55 394.63 Tm (x) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 262.55 394.63 Tm (Non-emergency care when traveling outside the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 262.55 380.86 Tm (U.S ) Tj ET EMC /Span <>BDC BT /F26 12 Tf 1 0 0 1 489.35 415.4 Tm (x) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 507.35 415.4 Tm (Private-duty nursing ) Tj ET EMC /Span <>BDC BT /F26 12 Tf 1 0 0 1 489.35 394.63 Tm (x) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 507.35 394.63 Tm (Routine foot care ) Tj ET EMC /Artifact <> BDC 0.5 w [] 0 d 0 0.39216 0.78431 RG -3.85 449.22 m -3.85 378.15 l S 1 w [] 0 d 0.75 w [] 0 d 759.95 449.22 m 759.95 378.15 l S 1 w [] 0 d 0.5 w [] 0 d -3.85 449.47 m 760.07 449.47 l S 1 w [] 0 d 0.75 w [] 0 d -3.22 433.84 m 759.2 433.84 l S 1 w [] 0 d 0.75 w [] 0 d -3.72 377.78 m 759.95 377.78 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 28 0 obj <>>>>> endobj 29 0 obj <>/Border[ 0 0 0]/StructParent 8/Rect[ 401.45 559.15 539.28 572.92]/Contents(www.DOL.gov forward slash EBSA forward slash health reform)/Subtype/Link>> endobj 31 0 obj <>/Border[ 0 0 0]/StructParent 9/Rect[ 650.88 545.38 733.99 559.15]/Contents(www.CCIIO.CMS.gov)/Subtype/Link>> endobj 33 0 obj <>/Border[ 0 0 0]/StructParent 10/Rect[ 217.11 517.84 309.52 531.61]/Contents(WWW dot health care dot gov)/Subtype/Link>> endobj 35 0 obj <>/Border[ 0 0 0]/StructParent 11/Rect[ 366.49 394.13 491.2 407.9]/Contents(HTTP colon forward slash forward slash WWW dot Michigan dot gov forward slash difs)/Subtype/Link>> endobj 37 0 obj <>/Border[ 0 0 0]/StructParent 12/Rect[ 505.42 394.13 622.04 407.9]/Contents(difs dash HICAP at michigan dot gov)/Subtype/Link>> endobj 45 0 obj <>stream q 0 0 792 612 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 18 18 cm 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 720.57 3.83 Tm (6) Tj ET BT /F5 12 Tf 1 0 0 1 726.05 3.83 Tm ( of) Tj ET BT /F4 12 Tf 1 0 0 1 736.99 3.83 Tm ( ) Tj ET BT /F4 12 Tf 1 0 0 1 739.73 3.83 Tm (8 ) Tj ET Q q Q EMC q 1 0 0 1 18 33.02 cm /Span <>BDC 0 0.50196 0.7451 rg BT /F4 12 Tf 1 0 0 1 0 542.61 Tm (Your Rights to Continue Coverage: ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 166.74 542.61 Tm (There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 528.84 Tm (Department of Labors Employee Benefits Security Administration at 1-866-444-3272 or ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 383.46 528.84 Tm (www.dol.gov/ebsa/healthreform) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG 383.89 527.13 m 520.84 527.13 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 521.29 528.84 Tm (, or the Department of Health and Human Services, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 515.07 Tm (Center for Consumer Information and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 630.15 515.07 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 632.88 515.07 Tm (www.cciio.cms.gov) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 633.32 513.36 m 715.55 513.36 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 715.99 515.07 Tm ( or by ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 501.3 Tm (calling 1-800-324-6172) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 100.66 501.3 Tm (.) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 103.4 501.3 Tm ( Other coverage options may be available to you too, including buying individual insurance coverage through the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 594.69 501.3 Tm (Health Insurance Marketplace) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 595.13 499.59 m 724.99 499.59 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 725.43 501.3 Tm (. 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This complaint is called a ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 712.76 459.86 Tm (grievance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 713.2 458.15 m 754.99 458.15 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 446.09 Tm (or ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 11.48 446.09 Tm (appeal) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 11.92 444.38 m 40.59 444.38 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 41.03 446.09 Tm (. For more information about your rights, look at the explanation of benefits you will receive for that medical ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 508.21 446.09 Tm (claim) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 508.64 444.38 m 530.73 444.38 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 531.17 446.09 Tm (. Your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 560.16 446.09 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 560.6 444.38 m 578.33 444.38 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 578.77 446.09 Tm ( documents also provide complete ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 432.32 Tm (information to submit a ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 102.29 432.32 Tm (claim) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 102.73 430.61 m 124.82 430.61 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 125.26 432.32 Tm (, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 130.73 432.32 Tm (appeal) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 131.17 430.61 m 159.84 430.61 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 160.28 432.32 Tm (, or a ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 185.44 432.32 Tm (grievance) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 185.88 430.61 m 227.67 430.61 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 228.11 432.32 Tm ( for any reason to your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 329.32 432.32 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 329.76 430.61 m 347.48 430.61 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.92 432.32 Tm (. For more information about your rights, this notice, or assistance,) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 636.75 432.32 Tm ( contact ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 673.96 432.32 Tm (MESSA by calling ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 418.55 Tm (1-800-336-0013. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 377.59 Tm (Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program \(HICAP\) Department of ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 363.82 Tm (Insurance and Financial Services, P. O. Box 30220, Lansing, MI 48909-7720) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 334.27 363.82 Tm ( or ) Tj ET EMC /Span <>BDC 0 0 1 rg BT /F5 12 Tf 1 0 0 1 348.49 363.82 Tm (http://www.michigan.gov/difs) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 1 RG 348.93 362.11 m 472.76 362.11 l S 1 w [] 0 d EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 473.2 363.82 Tm ( or ) Tj ET EMC /Span <>BDC 0 0 1 rg BT /F5 12 Tf 1 0 0 1 487.42 363.82 Tm (difs-HICAP@michigan.gov ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 487.86 362.11 m 603.6 362.11 l S 1 w [] 0 d EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 0 341.92 Tm (Does this ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 47.03 341.92 Tm (plan) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 67.26 341.92 Tm ( p) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 76.01 341.92 Tm (rovide Minimum Essential Coverage?) 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Tj ET EMC /Span <>BDC 0 0.50196 0.7451 rg BT /F4 14 Tf 1 0 0 1 224.75 288.61 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 227.94 288.61 Tm (Yes ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 270.97 Tm (If your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 30.09 270.97 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 30.53 269.26 m 48.25 269.26 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 48.69 270.97 Tm ( doesnt meet the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 126.93 270.97 Tm (Minimum Value Standards) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 127.37 269.26 m 241.9 269.26 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 242.34 270.97 Tm (, you may be eligible for a ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 357.22 270.97 Tm (premium tax credit) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 357.66 269.26 m 437.72 269.26 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 438.16 270.97 Tm ( to help you pay for a ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 532.82 270.97 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 533.26 269.26 m 550.98 269.26 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 551.43 270.97 Tm ( through the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 606.69 270.97 Tm (Marketplace) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 607.13 269.26 m 659.85 269.26 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 660.29 270.97 Tm (. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 257.2 Tm (\(IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit \(EHB\) categories as defined by ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 674.97 257.2 Tm (the State of ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 243.43 Tm (Michigan. The minim) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 90.79 243.43 Tm (um value of your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 166.28 243.43 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 166.72 241.72 m 184.44 241.72 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 184.88 243.43 Tm ( may be affected if your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 289.92 243.43 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 290.36 241.72 m 308.08 241.72 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 308.52 243.43 Tm ( does not cover certain EHB categories, such as ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 521.33 243.43 Tm (prescription drugs) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 521.77 241.72 m 599.1 241.72 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 599.54 243.43 Tm (, or if your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 646.04 243.43 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 646.48 241.72 m 664.2 241.72 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 664.64 243.43 Tm ( provides coverage ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 229.66 Tm (of specific EHB categories, for example ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 174.49 229.66 Tm (prescription drugs) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 174.93 227.95 m 252.27 227.95 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 252.71 229.66 Tm (, through another carrier.\) ) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 0 201.99 Tm (Language Access Services) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 126.9 201.99 Tm (: ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 132.91 201.99 Tm (See Addendum ) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 0 160.65 Tm () Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 120.4 160.65 Tm (To see examples of how this plan might cover costs for a sample medical situation, see the next section) Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 571.72 160.65 Tm (. ) Tj ET EMC /Span <>BDC 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FFb:/L`D!ٙ!g.Y\|}{SGW ry: }xhyq5OKkjgmPуzK*QԄAWrN"f>4gk:QI|0'#6ŗ4N%1X$O2%[AZCx(3ZGrusV̨D/NҊ8VIX#v@#r6G,΢ؐl Ȃiէf`x I?R!T >ýV.v^iW$Iۏw{jTŐb=>uﾍT-u Ќ aH Q|l;wo#|F^K}8|% ^dށoi"ତTݝڠ胝O srh`+:iD:s$.;ߔ\Q|w꣝lξ{sJcbxU#k`nZj} pb/gbSt'>BN)o {d?hͷ6 W"Z0cg@#_P+0+F3L11 ؔA5* P iuDˎKV{?~3 Ϡ6">Ƭk_zlw[yQSGyOZ}y()*1V#En?񭂎(QR"V g  !@B[KUNO^X)U44`b惣7Ibn G!V;`}=?i/'UظCAL:/mS < ^4`=J Q(N/gVOU0E4Tw&7>Ҟ?/,Z9 ?x>:/-W&5ǵұ̳8#A55ꇊc?!) E L@D>jCӟ9ht>6I .$V endstream endobj 505 0 obj <>stream q 0 0 792 612 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 18 18 cm 0 0 0 rg BT /F4 12 Tf 1 0 0 1 9.47 3.83 Tm ( ) Tj ET BT /F5 12 Tf 1 0 0 1 181.86 3.83 Tm (The ) Tj ET BT /F4 12 Tf 1 0 0 1 201.56 3.83 Tm (plan) Tj ET 2 J 0.879 w [] 0 d 0 0 0 RG 201.99 2.12 m 221.35 2.12 l S 1 w [] 0 d BT /F5 12 Tf 1 0 0 1 221.79 3.83 Tm ( would be responsible for the other costs of these EXAMPLE covered services. ) Tj ET 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 720.57 3.83 Tm (7) Tj ET BT /F5 12 Tf 1 0 0 1 726.05 3.83 Tm ( of) Tj ET BT /F4 12 Tf 1 0 0 1 736.99 3.83 Tm ( ) Tj ET BT /F4 12 Tf 1 0 0 1 739.73 3.83 Tm (8 ) Tj ET Q q Q EMC q 1 0 0 1 18 33.02 cm /Span <>BDC 0 0.50196 0.7451 rg BT /F4 12 Tf 1 0 0 1 0 556.04 Tm (91̽ these Coverage Examples: ) Tj ET EMC /Artifact <> BDC 0.93725 0.97647 1 RG 0 J 55.21 w 0 524.85 m 63.3 524.85 l S 1 w 55.21 w 63.3 524.85 m 741.5 524.85 l S 1 w EMC q 1 0 0 1 4.9 505.31 cm q n 0 0 m 51.48 0 l 51.48 47.15 l 0 47.15 l h W n /Artifact <> BDC q 51.48 0 0 47.15 0 0 cm /img12339 Do Q EMC Q Q q Q /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 68.7 541.27 Tm (This is not a cost estimator. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 201.59 541.27 Tm (Treatments shown are just examples of how this ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 414.92 541.27 Tm (plan) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG 415.36 539.55 m 433.08 539.55 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 433.52 541.27 Tm ( might cover medical care. Your actual costs will be different ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 68.7 527.5 Tm (depending on the actual care you receive, the prices your ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 321.46 527.5 Tm (providers) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 321.9 525.79 m 361.49 525.79 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 361.93 527.5 Tm ( charge, and many other factors. Focus on the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 566 527.5 Tm (cost sharing) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 566.43 525.79 m 618.62 525.79 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 619.06 527.5 Tm ( amounts \() Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 665.55 527.5 Tm (deductibles) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 665.99 525.79 m 714.9 525.79 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 715.34 527.5 Tm (, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 68.7 513.73 Tm (copayments) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 69.14 512.02 m 121.32 512.02 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 121.76 513.73 Tm ( and ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 143.65 513.73 Tm (coinsurance) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 144.09 512.02 m 196.27 512.02 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 196.72 513.73 Tm (\) and ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 221.88 513.73 Tm (excluded services) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 222.32 512.02 m 299.66 512.02 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 300.1 513.73 Tm ( under the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 347.16 513.73 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 347.6 512.02 m 365.32 512.02 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 365.76 513.73 Tm (. Use this information to compare the portion of costs you might pay under different ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 68.7 499.96 Tm (health ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 98.25 499.96 Tm (plans) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 98.69 498.25 m 121.33 498.25 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 121.77 499.96 Tm (. ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 127.25 499.96 Tm (Please note these coverage examples are based on self-only coverage. ) Tj ET EMC /Artifact <> BDC [] 0 d 0.22745 0.76078 0.95686 RG -0.5 552.46 m -0.5 497.25 l S [] 0 d [] 0 d 742 552.46 m 742 497.25 l S [] 0 d [] 0 d -0.5 552.96 m 742 552.96 l S [] 0 d [] 0 d -0.5 496.75 m 742 496.75 l S [] 0 d EMC /Artifact <> BDC 1 1 1 RG 0 J 400.5 w 229.5 294.78 m 243 294.78 l S 1 w 400.5 w 486 294.78 m 504 294.78 l S 1 w EMC /Artifact <> BDC 0.02745 0.45882 0.65882 RG 57.6 w 0.25 458.26 m 224.5 458.26 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F4 14 Tf 1 0 0 1 54.31 467 Tm (Peg is Having a Baby ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 29.24 452.93 Tm (\(9 months of in-network pre-natal care ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 61.77 439.16 Tm (and a hospital delivery\) ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 0.33725 0.62745 0.80392 RG 0 487.05 m 0 429.45 l S 1 w [] 0 d 0.5 w [] 0 d 224.75 487.05 m 224.75 429.45 l S 1 w [] 0 d 0.5 w [] 0 d 0 487.3 m 224.75 487.3 l S 1 w [] 0 d 0.5 w [] 0 d 0 429.2 m 224.75 429.2 l S 1 w [] 0 d EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F504 12 Tf 1 0 0 1 5.4 413.17 Tm () Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 14.36 413.17 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 17.09 413.17 Tm (The ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 37.33 413.17 Tm (plans) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 0 RG 37.77 411.46 m 65.33 411.46 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 65.77 413.17 Tm ( overall ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 102.97 413.17 Tm (deductible ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 103.41 411.46 m 151.74 411.46 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 192.35 413.17 Tm ($1,700 ) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F504 12 Tf 1 0 0 1 5.4 399.41 Tm () Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 14.36 399.41 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 17.09 399.41 Tm (Specialist) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 17.53 397.69 m 62.6 397.69 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 63.05 399.41 Tm ( ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 65.78 399.41 Tm (copayment ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 66.22 397.69 m 117.29 397.69 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 206.03 399.41 Tm ($50 ) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F504 12 Tf 1 0 0 1 5.4 385.64 Tm () Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 14.36 385.64 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 17.09 385.64 Tm (Hospital \(facility) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 93.1 385.64 Tm (\) ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 99.11 385.64 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 99.55 383.92 m 156.65 383.92 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 202.76 385.64 Tm (20% ) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F504 12 Tf 1 0 0 1 5.4 371.87 Tm () Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 14.36 371.87 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 17.09 371.87 Tm (Other ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 46.08 371.87 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 46.51 370.15 m 103.61 370.15 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 202.76 371.87 Tm (20% ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 0 344.33 Tm ( This EXAMPLE event includes services like: ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 330.69 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 5.47 330.69 Tm (Specialist) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 5.91 328.98 m 47.15 328.98 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 47.59 330.69 Tm ( office visits ) Tj ET EMC /Span <>BDC 0 0 0.25098 rg BT /F5 12 Tf 1 0 0 1 101.2 330.69 Tm (\() Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 104.47 330.69 Tm (prenatal care) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 161.91 330.69 Tm (\) ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 0 316.83 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 5.47 316.83 Tm (Childbirth/Delivery Professional Services ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 303.06 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 5.47 303.06 Tm (Childbirth/Delivery Facility Services ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 0 289.29 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 5.47 289.29 Tm (Diagnostic tests) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 5.91 287.58 m 74.5 287.58 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 74.94 289.29 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0.25098 rg BT /F5 12 Tf 1 0 0 1 77.68 289.29 Tm (\() Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 80.95 289.29 Tm (ultrasounds and blood work) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 201.31 289.29 Tm (\) ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 0 275.43 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 5.47 275.43 Tm (Specialist) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 5.91 273.72 m 47.15 273.72 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 47.59 275.43 Tm ( visit ) Tj ET EMC /Span <>BDC 0 0 0.25098 rg BT /F5 12 Tf 1 0 0 1 72.75 275.43 Tm (\() Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 76.03 275.43 Tm (anesthesia) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 123.63 275.43 Tm (\) ) Tj ET EMC /Artifact <> BDC 0.75294 0.9098 0.98431 RG 0 J 16.45 w 5.4 250.14 m 175.25 250.14 l S 1 w 16.45 w 175.75 250.14 m 225 250.14 l S 1 w EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 10.8 245.84 Tm (Total Example Cost ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 184.03 245.84 Tm ($12,700 ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 0.43922 0.68627 0.85098 RG 175.5 258.37 m 175.5 241.92 l S 1 w [] 0 d 0.5 w [] 0 d 5.65 258.62 m 225 258.62 l S 1 w [] 0 d 0.5 w [] 0 d 5.65 241.67 m 225 241.67 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 0 216.46 Tm ( In this ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 37.19 216.46 Tm (example, Peg would pay: ) Tj ET EMC /Artifact <> BDC 0.9098 0.96863 0.99216 RG 0 J 14.6 w 5.4 206.08 m 225 206.08 l S 1 w 1 1 1 RG 14.6 w 5.4 190.98 m 175.25 190.98 l S 1 w 14.6 w 175.75 190.98 m 225 190.98 l S 1 w 14.6 w 5.4 175.88 m 175.25 175.88 l S 1 w 14.6 w 175.75 175.88 m 225 175.88 l S 1 w 14.6 w 5.4 160.78 m 175.25 160.78 l S 1 w 14.6 w 175.75 160.78 m 225 160.78 l S 1 w 0.9098 0.96863 0.99216 RG 14.6 w 5.4 145.68 m 225 145.68 l S 1 w 1 1 1 RG 14.6 w 5.4 130.58 m 175.25 130.58 l S 1 w 14.6 w 175.75 130.58 m 225 130.58 l S 1 w 0.75294 0.9098 0.98431 RG 14.6 w 5.4 115.48 m 175.25 115.48 l S 1 w 14.6 w 175.75 115.48 m 225 115.48 l S 1 w EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 87.21 201.99 Tm (Cost) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG 87.65 200.28 m 107 200.28 l S 1 w [] 0 d EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 107.44 201.99 Tm ( ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 107.88 200.28 m 109.74 200.28 l S 1 w [] 0 d EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 110.18 201.99 Tm (Sharing ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 110.61 200.28 m 143.65 200.28 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 10.8 186.8 Tm (Deductibles ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 11.24 185.09 m 61.78 185.09 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 189.5 186.8 Tm ($1,700 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 10.8 171.7 Tm (Copayments ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 11.24 169.99 m 65.6 169.99 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 203.18 171.7 Tm ($10 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 10.8 156.6 Tm (Coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 11.24 154.89 m 65.6 154.89 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 189.5 156.6 Tm ($1,700 ) Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 74.72 141.59 Tm (What isnt covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 10.8 126.4 Tm (Limits or exclusions ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 203.18 126.4 Tm ($60 ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 10.8 111.17 Tm (The total Peg would pay is ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 189.5 111.17 Tm ($3,470 ) Tj ET EMC /Artifact <> BDC 0.5 w [] 0 d 0.43922 0.68627 0.85098 RG 175.5 198.28 m 175.5 153.48 l S 1 w [] 0 d 0.5 w [] 0 d 175.5 137.88 m 175.5 108.18 l S 1 w [] 0 d 0.5 w [] 0 d 5.65 213.63 m 224.75 213.63 l S 1 w [] 0 d 0.5 w [] 0 d 5.65 198.53 m 225 198.53 l S 1 w [] 0 d 0.5 w [] 0 d 5.65 183.43 m 225 183.43 l S 1 w [] 0 d 0.5 w [] 0 d 5.65 168.33 m 225 168.33 l S 1 w [] 0 d 0.5 w [] 0 d 5.65 153.23 m 225 153.23 l S 1 w [] 0 d 0.5 w [] 0 d 5.65 138.13 m 225 138.13 l S 1 w [] 0 d 0.5 w [] 0 d 5.65 123.03 m 225 123.03 l S 1 w [] 0 d 0.5 w [] 0 d 5.65 107.93 m 225 107.93 l S 1 w [] 0 d EMC /Artifact <> BDC 0.02745 0.45882 0.65882 RG 0 J 58 w 248.65 458.64 m 486.95 458.64 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F4 14 Tf 1 0 0 1 279.43 467.39 Tm (Managing Joes Type 2 Diabetes ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 290.13 453.32 Tm (\(a year of routine in-network care of ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 309.55 439.55 Tm (a well-controlled condition\) ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 0.33725 0.62745 0.80392 RG 248.4 487.64 m 248.4 429.64 l S 1 w [] 0 d 0.5 w [] 0 d 487.2 487.64 m 487.2 429.64 l S 1 w [] 0 d 0.5 w [] 0 d 248.4 487.89 m 487.2 487.89 l S 1 w [] 0 d 0.5 w [] 0 d 248.4 429.39 m 487.2 429.39 l S 1 w [] 0 d EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F5 12 Tf 1 0 0 1 253.8 413.36 Tm ( ) Tj ET EMC /Span <>BDC BT /F504 12 Tf 1 0 0 1 256.54 413.36 Tm () Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 265.5 413.36 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 268.23 413.36 Tm (The ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 288.46 413.36 Tm (plans) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 0 RG 288.9 411.65 m 316.46 411.65 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 316.9 413.36 Tm ( overall ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 354.11 413.36 Tm (deductible ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 354.55 411.65 m 402.88 411.65 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 449.35 413.36 Tm ($1,700 ) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F5 12 Tf 1 0 0 1 253.8 399.59 Tm ( ) Tj ET EMC /Span <>BDC BT /F504 12 Tf 1 0 0 1 256.54 399.59 Tm () Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 265.5 399.59 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 268.23 399.59 Tm (Specialist) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 268.67 397.88 m 313.74 397.88 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 314.18 399.59 Tm ( ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 316.92 399.59 Tm (copayment ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 317.36 397.88 m 368.42 397.88 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 463.03 399.59 Tm ($50 ) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F5 12 Tf 1 0 0 1 253.8 385.83 Tm ( ) Tj ET EMC /Span <>BDC BT /F504 12 Tf 1 0 0 1 256.54 385.83 Tm () Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 265.5 385.83 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 268.23 385.83 Tm (Hospital \(facility\)) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 347.52 385.83 Tm ( ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 350.25 385.83 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 350.69 384.11 m 407.78 384.11 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 459.76 385.83 Tm (20% ) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F5 12 Tf 1 0 0 1 253.8 372.06 Tm ( ) Tj ET EMC /Span <>BDC BT /F504 12 Tf 1 0 0 1 256.54 372.06 Tm () Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 265.5 372.06 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 268.23 372.06 Tm (Othe) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 290.65 372.06 Tm (r ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 297.21 372.06 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 297.65 370.34 m 354.74 370.34 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 459.76 372.06 Tm (20% ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 248.4 344.52 Tm ( This EXAMPLE event includes services like: ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 248.4 330.88 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 253.87 330.88 Tm (Primary care physician) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 254.31 329.16 m 352.96 329.16 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 353.41 330.88 Tm ( office visits) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 404.28 330.88 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0.25098 rg BT /F5 12 Tf 1 0 0 1 407.01 330.88 Tm (\() Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 410.29 330.88 Tm (including ) Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 248.4 317.11 Tm ( disease education\) ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 248.4 303.25 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 253.87 303.25 Tm (Diagnostic tests) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 254.31 301.54 m 322.9 301.54 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 323.34 303.25 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0.25098 rg BT /F5 12 Tf 1 0 0 1 326.08 303.25 Tm (\() Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 329.35 303.25 Tm (blood work) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 376.94 303.25 Tm (\) ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 248.4 289.39 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 253.87 289.39 Tm (Prescription drugs ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 254.31 287.68 m 332.74 287.68 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 248.4 275.62 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 253.87 275.62 Tm (Durable medical equipment) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 254.31 273.91 m 373.22 273.91 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 373.66 275.62 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0.25098 rg BT /F5 12 Tf 1 0 0 1 376.4 275.62 Tm (\() Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 379.67 275.62 Tm (glucose meter) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 441.48 275.62 Tm (\) ) Tj ET EMC /Artifact <> BDC 0.75294 0.9098 0.98431 RG 0 J 14.6 w 253.8 251.83 m 429.05 251.83 l S 1 w 14.6 w 429.55 251.83 m 483.3 251.83 l S 1 w EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 259.2 247.52 Tm (Total Example Cost ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 447.8 247.52 Tm ($5,600 ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 0.43922 0.68627 0.85098 RG 429.3 259.13 m 429.3 244.53 l S 1 w [] 0 d 0.5 w [] 0 d 254.05 259.38 m 483.3 259.38 l S 1 w [] 0 d 0.5 w [] 0 d 254.05 244.28 m 483.3 244.28 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 248.4 216.78 Tm ( In this ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 285.59 216.78 Tm (example, Joe would pay: ) Tj ET EMC /Artifact <> BDC 0.9098 0.96863 0.99216 RG 0 J 14.6 w 253.8 206.4 m 483.3 206.4 l S 1 w 1 1 1 RG 14.6 w 253.8 191.3 m 429.05 191.3 l S 1 w 14.6 w 429.55 191.3 m 483.3 191.3 l S 1 w 14.6 w 253.8 176.2 m 429.05 176.2 l S 1 w 14.6 w 429.55 176.2 m 483.3 176.2 l S 1 w 14.6 w 253.8 161.1 m 429.05 161.1 l S 1 w 14.6 w 429.55 161.1 m 483.3 161.1 l S 1 w 0.9098 0.96863 0.99216 RG 14.6 w 253.8 146 m 483.3 146 l S 1 w 1 1 1 RG 14.6 w 253.8 130.9 m 429.05 130.9 l S 1 w 14.6 w 429.55 130.9 m 483.3 130.9 l S 1 w 0.75294 0.9098 0.98431 RG 14.6 w 253.8 115.8 m 429.05 115.8 l S 1 w 14.6 w 429.55 115.8 m 483.3 115.8 l S 1 w EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 340.11 202.31 Tm (Cost) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG 340.55 200.6 m 359.9 200.6 l S 1 w [] 0 d EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 360.34 202.31 Tm ( ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 360.78 200.6 m 362.64 200.6 l S 1 w [] 0 d EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 363.08 202.31 Tm (Sharing ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 363.52 200.6 m 396.55 200.6 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 259.2 187.12 Tm (Deductibles ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 259.64 185.41 m 310.18 185.41 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 447.8 187.12 Tm ($1,700 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 259.2 172.02 Tm (Copayments ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 259.64 170.31 m 314 170.31 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 456.01 172.02 Tm ($600 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 259.2 156.92 Tm (Coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 259.64 155.21 m 314 155.21 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 456.01 156.92 Tm ($100 ) Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 328.07 141.91 Tm (What isnt covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 259.2 126.72 Tm (Limits or exclusions ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 461.48 126.72 Tm ($20 ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 259.2 111.49 Tm (The total Joe would pay is ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 447.8 111.49 Tm ($2,420 ) Tj ET EMC /Artifact <> BDC 0.5 w [] 0 d 0.43922 0.68627 0.85098 RG 429.3 198.6 m 429.3 153.8 l S 1 w [] 0 d 0.5 w [] 0 d 429.3 138.2 m 429.3 108.5 l S 1 w [] 0 d 0.5 w [] 0 d 254.05 213.95 m 483.05 213.95 l S 1 w [] 0 d 0.5 w [] 0 d 254.05 198.85 m 483.3 198.85 l S 1 w [] 0 d 0.5 w [] 0 d 254.05 183.75 m 483.3 183.75 l S 1 w [] 0 d 0.5 w [] 0 d 254.05 168.65 m 483.3 168.65 l S 1 w [] 0 d 0.5 w [] 0 d 254.05 153.55 m 483.3 153.55 l S 1 w [] 0 d 0.5 w [] 0 d 254.05 138.45 m 483.3 138.45 l S 1 w [] 0 d 0.5 w [] 0 d 254.05 123.35 m 483.3 123.35 l S 1 w [] 0 d 0.5 w [] 0 d 254.05 108.25 m 483.3 108.25 l S 1 w [] 0 d EMC /Artifact <> BDC 0.02745 0.45882 0.65882 RG 0 J 58.45 w 509.65 458.42 m 742 458.42 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F4 14 Tf 1 0 0 1 566.49 467.23 Tm (Mias Simple Fracture ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 543.79 453.03 Tm (\() Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 547.06 453.03 Tm (in-network emergency room visit and ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 593.83 439.26 Tm (follow up care\) ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 0.33725 0.62745 0.80392 RG 509.4 487.64 m 509.4 429.19 l S 1 w [] 0 d 0.5 w [] 0 d 742.25 487.64 m 742.25 429.19 l S 1 w [] 0 d 0.5 w [] 0 d 509.4 487.89 m 742.25 487.89 l S 1 w [] 0 d 0.5 w [] 0 d 509.4 428.95 m 742.25 428.95 l S 1 w [] 0 d EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F504 12 Tf 1 0 0 1 514.8 412.91 Tm () Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 523.76 412.91 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 526.5 412.91 Tm (The ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 546.73 412.91 Tm (plans) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 0 RG 547.17 411.2 m 574.73 411.2 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 575.17 412.91 Tm ( overall ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 612.37 412.91 Tm (deductible ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 612.81 411.2 m 661.14 411.2 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 705.85 412.91 Tm ($1,700 ) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F504 12 Tf 1 0 0 1 514.8 399.14 Tm () Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 523.76 399.14 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 526.5 399.14 Tm (Specialist) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 526.93 397.43 m 572.01 397.43 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 572.45 399.14 Tm ( ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 575.18 399.14 Tm (copayment ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 575.62 397.43 m 626.69 397.43 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 719.53 399.14 Tm ($50 ) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F504 12 Tf 1 0 0 1 514.8 385.38 Tm () Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 523.76 385.38 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 526.5 385.38 Tm (Hospital \(facility\)) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 605.78 385.38 Tm ( ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 608.52 385.38 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 608.95 383.66 m 666.05 383.66 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 716.26 385.38 Tm (20% ) Tj ET EMC /Span <>BDC 0.02745 0.45882 0.65882 rg BT /F504 12 Tf 1 0 0 1 514.8 371.61 Tm () Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 523.76 371.61 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 526.5 371.61 Tm (Othe) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 548.91 371.61 Tm (r ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 555.48 371.61 Tm (coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 555.91 369.89 m 613.01 369.89 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 716.26 371.61 Tm (20% ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 509.4 344.07 Tm ( This EXAMPLE event includes services like: ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 509.4 330.43 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 514.87 330.43 Tm (Emergency room care) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 515.31 328.71 m 611.23 328.71 l S 1 w [] 0 d EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 611.67 330.43 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0.25098 rg BT /F5 12 Tf 1 0 0 1 614.41 330.43 Tm (\() Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 617.69 330.43 Tm (including medical ) Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 509.4 316.66 Tm ( supplies\) ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 509.4 302.8 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 514.87 302.8 Tm (Diagnostic tests) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 515.31 301.09 m 583.9 301.09 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 584.34 302.8 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0.25098 rg BT /F5 12 Tf 1 0 0 1 587.08 302.8 Tm (\() Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 590.35 302.8 Tm (x-ray) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 612.22 302.8 Tm (\) ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 509.4 288.94 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 514.87 288.94 Tm (Durable medical equipment) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 515.31 287.23 m 634.22 287.23 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 634.66 288.94 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0.25098 rg BT /F5 12 Tf 1 0 0 1 637.4 288.94 Tm (\() Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 640.67 288.94 Tm (crutches) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 677.87 288.94 Tm (\) ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F5 12 Tf 1 0 0 1 509.4 275.08 Tm ( ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 514.87 275.08 Tm (Rehabilitation services) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 515.31 273.37 m 612.89 273.37 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 613.33 275.08 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0.25098 rg BT /F5 12 Tf 1 0 0 1 616.06 275.08 Tm (\() Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 619.34 275.08 Tm (physical therapy) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 690.46 275.08 Tm (\) ) Tj ET EMC /Artifact <> BDC 0.75294 0.9098 0.98431 RG 0 J 14.6 w 514.8 253.01 m 690.05 253.01 l S 1 w 14.6 w 690.55 253.01 m 742.5 253.01 l S 1 w EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 520.2 248.71 Tm (Total Example Cost ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 707 248.71 Tm ($2,800 ) Tj ET EMC /Artifact <> BDC 2 J 0.5 w [] 0 d 0.43922 0.68627 0.85098 RG 690.3 260.31 m 690.3 245.71 l S 1 w [] 0 d 0.5 w [] 0 d 515.05 260.56 m 742.5 260.56 l S 1 w [] 0 d 0.5 w [] 0 d 515.05 245.46 m 742.5 245.46 l S 1 w [] 0 d EMC /Span <>BDC 0 0 0.25098 rg BT /F5 12 Tf 1 0 0 1 509.4 217.96 Tm ( ) Tj ET EMC /Span <>BDC 0 0 0 rg BT /F4 12 Tf 1 0 0 1 514.87 217.96 Tm (In this ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 546.59 217.96 Tm (example, Mia would pay: ) Tj ET EMC /Artifact <> BDC 0.9098 0.96863 0.99216 RG 0 J 14.6 w 514.8 207.58 m 742.5 207.58 l S 1 w 1 1 1 RG 14.6 w 514.8 192.48 m 686.15 192.48 l S 1 w 14.6 w 686.65 192.48 m 742.5 192.48 l S 1 w 14.6 w 514.8 177.38 m 686.15 177.38 l S 1 w 14.6 w 686.65 177.38 m 742.5 177.38 l S 1 w 14.6 w 514.8 162.28 m 686.15 162.28 l S 1 w 14.6 w 686.65 162.28 m 742.5 162.28 l S 1 w 0.9098 0.96863 0.99216 RG 14.6 w 514.8 147.18 m 742.5 147.18 l S 1 w 1 1 1 RG 14.6 w 514.8 132.08 m 686.15 132.08 l S 1 w 14.6 w 686.65 132.08 m 742.5 132.08 l S 1 w 0.75294 0.9098 0.98431 RG 14.6 w 514.8 116.98 m 686.15 116.98 l S 1 w 14.6 w 686.65 116.98 m 742.5 116.98 l S 1 w EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 600.21 203.49 Tm (Cost) Tj ET EMC /Artifact <> BDC 2 J 0.879 w [] 0 d 0 0 0 RG 600.65 201.78 m 620 201.78 l S 1 w [] 0 d EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 620.44 203.49 Tm ( ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 620.88 201.78 m 622.74 201.78 l S 1 w [] 0 d EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 623.18 203.49 Tm (Sharing ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 623.62 201.78 m 656.65 201.78 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 520.2 188.3 Tm (Deductibles ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 520.64 186.59 m 571.17 186.59 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 707 188.3 Tm ($1,700 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 520.2 173.2 Tm (Copayments ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 520.64 171.49 m 575 171.49 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 726.16 173.2 Tm ($0 ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 520.2 158.1 Tm (Coinsurance ) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 520.64 156.39 m 575 156.39 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 720.68 158.1 Tm ($70 ) Tj ET EMC /Span <>BDC BT /F43 12 Tf 1 0 0 1 588.17 143.09 Tm (What isnt covered ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 520.2 127.9 Tm (Limits or exclusions ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 726.16 127.9 Tm ($0 ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 520.2 112.67 Tm (The total Mia would pay is ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 704.26 112.67 Tm ( ) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 707 112.67 Tm ($1,770 ) Tj ET EMC /Artifact <> BDC 0.5 w [] 0 d 0.43922 0.68627 0.85098 RG 686.4 199.78 m 686.4 154.98 l S 1 w [] 0 d 0.5 w [] 0 d 686.4 139.38 m 686.4 109.68 l S 1 w [] 0 d 0.5 w [] 0 d 515.05 215.13 m 742.25 215.13 l S 1 w [] 0 d 0.5 w [] 0 d 515.05 200.03 m 742.5 200.03 l S 1 w [] 0 d 0.5 w [] 0 d 515.05 184.93 m 742.5 184.93 l S 1 w [] 0 d 0.5 w [] 0 d 515.05 169.83 m 742.5 169.83 l S 1 w [] 0 d 0.5 w [] 0 d 515.05 154.73 m 742.5 154.73 l S 1 w [] 0 d 0.5 w [] 0 d 515.05 139.63 m 742.5 139.63 l S 1 w [] 0 d 0.5 w [] 0 d 515.05 124.53 m 742.5 124.53 l S 1 w [] 0 d 0.5 w [] 0 d 515.05 109.43 m 742.5 109.43 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 36.35 80.37 Tm (If you are also covered by an account-type ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 224.55 80.37 Tm (plan) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 0 0 0 RG 224.99 78.66 m 242.72 78.66 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 243.16 80.37 Tm ( such as an integrated health flexible spending arrangement \(FSA\), health reimbursement arrangement ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 36.35 66.6 Tm (\(HRA\), and/or a health savings account \(HSA\), then you may have access to additional funds to help cover certain ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 536.35 66.6 Tm (out-of-pocket expenses) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 536.79 64.89 m 638.21 64.89 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 638.65 66.6 Tm ( like the ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 36.35 52.83 Tm (deductible) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 36.79 51.12 m 80.78 51.12 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 81.22 52.83 Tm (, ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 86.69 52.83 Tm (copayments) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 87.13 51.12 m 139.31 51.12 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 139.75 52.83 Tm (, or ) Tj ET EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 156.71 52.83 Tm (coinsurance) Tj ET EMC /Artifact <> BDC 0.879 w [] 0 d 157.15 51.12 m 209.33 51.12 l S 1 w [] 0 d EMC /Span <>BDC BT /F5 12 Tf 1 0 0 1 209.77 52.83 Tm (, or benefits not otherwise covered. ) Tj ET EMC /Artifact <> BDC 0.5 w [] 0 d 30.6 92.88 m 30.6 48.67 l S 1 w [] 0 d 0.5 w [] 0 d 714.6 92.88 m 714.6 48.67 l S 1 w [] 0 d 0.5 w [] 0 d 30.6 93.13 m 714.6 93.13 l S 1 w [] 0 d 0.5 w [] 0 d 30.6 48.42 m 714.6 48.42 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 506 0 obj <>/Font<>>>>> endobj 502 0 obj <> endobj 508 0 obj <> endobj 509 0 obj <> endobj 510 0 obj <> endobj 511 0 obj <> endobj 512 0 obj <> endobj 513 0 obj <> endobj 514 0 obj <> endobj 515 0 obj <> endobj 516 0 obj <> endobj 517 0 obj <> endobj 518 0 obj <> endobj 519 0 obj <> endobj 520 0 obj <> endobj 521 0 obj <> endobj 522 0 obj <> endobj 523 0 obj <> endobj 524 0 obj <> endobj 525 0 obj <> endobj 526 0 obj <> endobj 527 0 obj <> endobj 528 0 obj <> endobj 529 0 obj <> endobj 530 0 obj <> endobj 531 0 obj <> endobj 532 0 obj <> endobj 533 0 obj <> endobj 534 0 obj <> endobj 535 0 obj <> endobj 536 0 obj <> endobj 537 0 obj <> endobj 538 0 obj <> endobj 540 0 obj <> 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#Zv)Gf x.!I_:I;2g,Io,e*M}*;Vaez-]We30 ajNeX٠H&h&K{m$BWHT޿ca>]`'$>\ryS>Sm Pg{,̳ #Ap(S2ݬF!dȶ2Ǹ)\KʞX_/s̓,ad%BNGˬE nHdXSIW2D 0 Cc ɶ&g-ߖi"|.X9 vchGoZ\528b9D.b ~qPIѠ ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (wqjWdhceu i! ono5\>v0uIiuZ}ƚ=:hh#); 5iL)m#&,'øŷءeX<{kp& e\2* #+Y$YO:IeLi%YH)| (Ӿ7dp׊.H]6g}K)tz]iIJn@ i]iqxnlGߢ`,+ [[-]ײC )-irJ| ۰3/ .}ous5v4's5^JӴO {T r ~hG&ukmw Ӣ`WN;"Kxl^Ʌ.2C?6Ү>w=rbn`t/,;etQcɑ8_g1swd(3ƶsE¥;`*wZއywyow1Z][E=E]C$7  ish"efȭR ]4;T'*><\Snnƥ%Ѻ!70> endobj 507 0 obj <> endobj 602 0 obj <> endobj 601 0 obj <> endobj 603 0 obj [ 47 0 R 47 0 R 47 0 R 47 0 R 49 0 R 49 0 R 50 0 R 52 0 R 53 0 R 54 0 R 54 0 R 54 0 R 54 0 R 54 0 R 54 0 R 54 0 R 55 0 R 56 0 R 56 0 R 56 0 R 56 0 R 56 0 R 56 0 R 56 0 R 56 0 R 56 0 R 56 0 R 57 0 R 57 0 R 11 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 13 0 R 57 0 R 57 0 R 57 0 R 57 0 R 57 0 R 58 0 R 61 0 R 63 0 R 66 0 R 69 0 R 72 0 R 72 0 R 72 0 R 75 0 R 75 0 R 77 0 R 77 0 R 79 0 R 79 0 R 79 0 R 79 0 R 79 0 R 79 0 R 79 0 R 82 0 R 82 0 R 82 0 R 82 0 R 85 0 R 85 0 R 85 0 R 85 0 R 85 0 R 85 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 87 0 R 89 0 R 89 0 R 89 0 R 89 0 R 92 0 R 94 0 R 94 0 R 94 0 R 100 0 R 100 0 R 100 0 R 100 0 R 100 0 R 100 0 R 102 0 R 102 0 R 102 0 R 104 0 R 104 0 R 106 0 R 106 0 R 108 0 R 108 0 R 108 0 R 110 0 R 110 0 R 110 0 R 110 0 R 110 0 R 110 0 R 110 0 R 113 0 R 113 0 R 113 0 R 113 0 R 113 0 R 113 0 R 113 0 R 113 0 R 115 0 R 115 0 R 115 0 R 117 0 R 117 0 R 117 0 R 120 0 R 120 0 R 120 0 R 120 0 R 120 0 R 120 0 R 120 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 124 0 R 124 0 R 124 0 R 124 0 R 124 0 R 124 0 R 127 0 R 129 0 R 129 0 R 129 0 R 129 0 R 129 0 R ] endobj 604 0 obj [ 131 0 R 133 0 R 133 0 R 133 0 R 133 0 R 133 0 R 133 0 R 133 0 R 133 0 R 133 0 R 134 0 R 137 0 R 139 0 R 141 0 R 141 0 R 144 0 R 144 0 R 147 0 R 147 0 R 150 0 R 150 0 R 150 0 R 153 0 R 153 0 R 153 0 R 155 0 R 155 0 R 155 0 R 157 0 R 157 0 R 159 0 R 159 0 R 159 0 R 162 0 R 162 0 R 165 0 R 165 0 R 165 0 R 167 0 R 167 0 R 169 0 R 171 0 R 171 0 R 171 0 R 171 0 R 171 0 R 174 0 R 174 0 R 174 0 R 174 0 R 176 0 R 178 0 R 178 0 R 178 0 R 178 0 R 178 0 R 178 0 R 178 0 R 178 0 R 178 0 R 178 0 R 180 0 R 183 0 R 183 0 R 183 0 R 185 0 R 185 0 R 187 0 R 187 0 R 189 0 R 191 0 R 191 0 R 194 0 R 194 0 R 196 0 R 196 0 R 198 0 R 198 0 R ] endobj 605 0 obj [ 200 0 R 200 0 R 202 0 R 202 0 R 202 0 R 20 0 R 204 0 R 206 0 R 206 0 R 206 0 R 206 0 R 206 0 R 206 0 R 206 0 R 208 0 R 208 0 R 208 0 R 208 0 R 208 0 R 210 0 R 210 0 R 210 0 R 210 0 R 210 0 R 210 0 R 210 0 R 212 0 R 212 0 R 215 0 R 215 0 R 215 0 R 215 0 R 215 0 R 215 0 R 215 0 R 217 0 R 217 0 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0 R 500 0 R 500 0 R 42 0 R 42 0 R 42 0 R 501 0 R 501 0 R 501 0 R 501 0 R 501 0 R ] endobj 609 0 obj [ 502 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 508 0 R 509 0 R 509 0 R 509 0 R 510 0 R 510 0 R 510 0 R 510 0 R 510 0 R 510 0 R 511 0 R 512 0 R 512 0 R 512 0 R 512 0 R 512 0 R 513 0 R 514 0 R 514 0 R 514 0 R 514 0 R 514 0 R 515 0 R 516 0 R 516 0 R 516 0 R 516 0 R 517 0 R 518 0 R 519 0 R 519 0 R 519 0 R 519 0 R 519 0 R 519 0 R 520 0 R 520 0 R 521 0 R 521 0 R 522 0 R 522 0 R 522 0 R 522 0 R 522 0 R 522 0 R 523 0 R 523 0 R 523 0 R 523 0 R 523 0 R 523 0 R 524 0 R 525 0 R 526 0 R 526 0 R 527 0 R 527 0 R 527 0 R 528 0 R 529 0 R 530 0 R 531 0 R 532 0 R 533 0 R 534 0 R 535 0 R 536 0 R 537 0 R 538 0 R 541 0 R 541 0 R 541 0 R 542 0 R 542 0 R 542 0 R 542 0 R 542 0 R 542 0 R 542 0 R 543 0 R 544 0 R 544 0 R 544 0 R 544 0 R 544 0 R 544 0 R 545 0 R 546 0 R 546 0 R 546 0 R 546 0 R 546 0 R 546 0 R 547 0 R 548 0 R 548 0 R 548 0 R 548 0 R 548 0 R 548 0 R 549 0 R 550 0 R 551 0 R 551 0 R 551 0 R 551 0 R 551 0 R 551 0 R 551 0 R 552 0 R 552 0 R 552 0 R 552 0 R 552 0 R 552 0 R 553 0 R 553 0 R 554 0 R 554 0 R 554 0 R 554 0 R 554 0 R 554 0 R 555 0 R 556 0 R 557 0 R 557 0 R 558 0 R 558 0 R 558 0 R 559 0 R 560 0 R 561 0 R 562 0 R 563 0 R 564 0 R 565 0 R 566 0 R 567 0 R 568 0 R 569 0 R 570 0 R 570 0 R 570 0 R 570 0 R 571 0 R 571 0 R 571 0 R 571 0 R 571 0 R 571 0 R 572 0 R 573 0 R 573 0 R 573 0 R 573 0 R 573 0 R 574 0 R 575 0 R 575 0 R 575 0 R 575 0 R 575 0 R 576 0 R 577 0 R 577 0 R 577 0 R 577 0 R 577 0 R 578 0 R 579 0 R 580 0 R 580 0 R 580 0 R 580 0 R 580 0 R 580 0 R 581 0 R 581 0 R 581 0 R 581 0 R 581 0 R 581 0 R 582 0 R 582 0 R 582 0 R 582 0 R 582 0 R 582 0 R 583 0 R 583 0 R 583 0 R 583 0 R 583 0 R 583 0 R 584 0 R 585 0 R 586 0 R 586 0 R 586 0 R 587 0 R 587 0 R 587 0 R 588 0 R 589 0 R 590 0 R 591 0 R 592 0 R 593 0 R 594 0 R 595 0 R 596 0 R 597 0 R 598 0 R 598 0 R 599 0 R 599 0 R 599 0 R 599 0 R 599 0 R 599 0 R 599 0 R 599 0 R 599 0 R 599 0 R 599 0 R 599 0 R ] endobj 610 0 obj [] endobj 611 0 obj <>stream q 0 0 792 612 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 18 18 cm 0.02745 0.45882 0.65882 rg BT /F4 12 Tf 1 0 0 1 720.57 3.83 Tm (8) Tj ET BT /F5 12 Tf 1 0 0 1 726.05 3.83 Tm ( of) Tj ET BT /F4 12 Tf 1 0 0 1 736.99 3.83 Tm ( ) Tj ET BT /F4 12 Tf 1 0 0 1 739.73 3.83 Tm (8 ) Tj ET Q q Q EMC q 1 0 0 1 18 33.02 cm q 1 0 0 1 0 28.73 cm q n 0 0 m 724.5 0 l 724.5 538.5 l 0 538.5 l h W n /Artifact <> BDC q 727.26 0 0 538.5 -1.38 0 cm /img12341 Do Q EMC Q Q q Q Q q Q Q endstream endobj 3 0 obj <> endobj 4 0 obj <> endobj 5 0 obj <> endobj 8 0 obj <> endobj 26 0 obj <> endobj 43 0 obj <> endobj 44 0 obj <> endobj 504 0 obj <> endobj 14 0 obj <> endobj 612 0 obj <>stream application/pdf Benefits Document 2025-09-22T15:56:46+03:56 2025-09-22T15:56:46+03:56 2025-09-22T15:56:46+03:56 xPression 23.4 Patch 10 / / JPDF 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2025-10-07T11:39:28-04:00 2025-10-07T11:39:28-04:00 uuid:a94c6f33-ea02-47b3-b8c4-509bdfd9a1bd uuid:d605778f-bfb3-42c7-9854-8810b4ea26c0 xPression 23.4 Patch 10 / / JPDF 1 uuid:413a18b0-d128-4440-8040-ba753dd76c80 uuid:307b630a-2a02-45e2-82fd-578d6ec51990 endstream endobj 638 0 obj <> endobj 639 0 obj <> endobj 640 0 obj <>stream q 0 0 792 612 re W n /Artifact <>BDC EMC BT /Artifact <>BDC 0 0 0 rg /TT0 12 Tf 18 21.83 Td ( )Tj /TT1 12 Tf 1 0 0 1 21 21.83 Tm (Group Number 71452, 71453 - 225/226 )Tj /TT2 12 Tf 598.9 0.13 Td (SBC000008046115 )Tj 0.027 0.459 0.659 rg /TT1 12 Tf 118.67 -0.13 Td [(1)-0.667 ( )]TJ /TT2 12 Tf 8.21 0 Td (of)Tj /TT1 12 Tf ( 8 )Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0.949 0.949 0.949 RG 3.6 w q 1 0 0 1 -10.25 503.5 cm 0 0 m 770.25 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.584 0.702 0.843 RG 3.6 w q 1 0 0 1 -10.25 499.9 cm 0 0 m 770.25 0 l S Q Q EMC BT /Span <>BDC 0 0 0 rg 13.5 592.36 Td (Summary of Benefits and Coverage: )Tj EMC /Span <>BDC /TT2 12 Tf 172.24 0 Td (What this Plan Covers & What You Pay )Tj EMC /Span <>BDC 175.03 0 Td (f)Tj EMC /Span <>BDC (or Covered Services)Tj EMC /Span <>BDC 0.027 0.459 0.659 rg /TT1 12 Tf 134.23 -0.06 Td (Coverage Period: )Tj EMC /Span <>BDC 84.21 0 Td (Beginning on or after 01/01/2026 )Tj EMC ET q 1 0 0 1 13.5 539.02 cm 0 0 m 114.55 0 l 114.55 45.05 l 0 45.05 l h W n /Figure <>BDC q 114.55 0 0 45.05 0 0 cm /Im0 Do Q EMC Q /Span <>BDC EMC q 1 0 0 1 659.2 560.16 cm 0 0 m 111.6 0 l 111.6 28.8 l 0 28.8 l h W n /Artifact <>BDC q 111.6 0 0 28.8 0 0 cm /Im1 Do Q EMC Q /Span <>BDC Q BT 0.027 0.459 0.659 rg /TT1 16 Tf 157.08 568.81 Td (MESSA Balance)Tj 0.027 0.459 0.659 RG 0.457 w /C2_0 16 Tf 2 Tr 100.617 0 Td <000E>Tj /TT1 16 Tf 0 Tr 1 0 0 1 265.3613 568.81 Tm ( & Balance)Tj /C2_0 16 Tf 2 Tr 67.086 0 Td <000E>Tj /TT1 16 Tf 0 Tr 1 0 0 1 340.1113 568.81 Tm ( RX )Tj /TT1 12 Tf -183.031 -23.88 Td (PPO )Tj ET EMC q 0 0 792 612 re W n BT /Span <>BDC 0 0 0 rg 494 545 Td (Coverage for:)Tj EMC /Span <>BDC /TT2 12 Tf 63.97 0 Td ( )Tj EMC /Span <>BDC 2.73 0 Td (Individual/Family)Tj EMC /Span <>BDC 73.29 0 Td ( | )Tj EMC /Span <>BDC /TT1 12 Tf 8.03 0 Td (Plan Type:)Tj EMC /Span <>BDC /TT2 12 Tf 49.76 0 Td ( )Tj EMC /Span <>BDC (PPO)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0.937 0.976 1 RG 27.54 w q 1 0 0 1 -6.63 476.79 cm 0 0 m 54.66 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.937 0.976 1 RG 27.54 w q 1 0 0 1 48.03 476.79 cm 0 0 m 714.1 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.937 0.976 1 RG 41.44 w q 1 0 0 1 -6.63 442.3 cm 0 0 m 768.76 0 l S Q Q EMC BT /Span <>BDC /TT3 4 Tf 16.52 496.58 Td ( )Tj EMC ET q 1 0 0 1 20.97 496.58 cm 0 0 m 36.2 0 l 36.2 27 l 0 27 l h W n /Artifact <>BDC q 36.2 0 0 27 0 0 cm /Im2 Do Q EMC Q BT /Span <>BDC /TT1 12 Tf 71.43 512.39 Td (The Summary of Benefits and Coverage \(SBC\) document will help you choo\ se a health )Tj EMC /Span <>BDC 407.92 0 Td (plan)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 461.79 477.66 cm 0 0 m 19.35 0 l S Q Q EMC BT /Span <>BDC 499.58 512.39 Td (. The SBC shows you how you and the )Tj EMC /Span <>BDC 183.18 0 Td (plan)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 665.2 477.66 cm 0 0 m 19.35 0 l S Q Q EMC BT /Span <>BDC 703 512.39 Td ( would share )Tj EMC /Span <>BDC -631.57 -13.77 Td (the cost for covered health care services. NOTE: Information about the c\ ost of this )Tj EMC /Span <>BDC 388.79 0 Td (plan)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 442.66 463.89 cm 0 0 m 19.36 0 l S Q Q EMC BT /Span <>BDC 480.46 498.62 Td ( \(called the )Tj EMC /Span <>BDC 54.14 0 Td (premium)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 517.04 463.89 cm 0 0 m 40.68 0 l S Q Q EMC BT /Span <>BDC 576.16 498.62 Td (\) will be provided separately. )Tj EMC /Span <>BDC -559.64 -13.77 Td (This is only a summary. )Tj EMC /Span <>BDC /TT2 12 Tf 114.32 0 Td (For more information about your coverage, or to get a copy of the comple\ te terms of coverage, visit )Tj EMC /Span <>BDC 0 0 1 rg 433.81 0 Td (www.messa.org)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 1 RG 0.879 w 2 J q 1 0 0 1 547.09 450.12 cm 0 0 m 69.1 0 l S Q Q EMC BT /Span <>BDC 0 0 0 rg 634.63 484.85 Td ( or call )Tj EMC /Span <>BDC 31.72 0 Td (MESSA at 1-800-336-)Tj EMC /Span <>BDC -649.83 -13.77 Td (0013)Tj EMC /Span <>BDC 21.9 0 Td (. For general definitions of common terms, such as )Tj EMC /Span <>BDC 223.72 0 Td (allowed amount)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 244.58 436.35 cm 0 0 m 68.05 0 l S Q Q EMC BT /Span <>BDC 331.07 471.08 Td (, )Tj EMC /Span <>BDC (balance billing)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 318.98 436.35 cm 0 0 m 61.49 0 l S Q Q EMC BT /Span <>BDC 398.91 471.08 Td (, )Tj EMC /Span <>BDC (coinsurance)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 386.82 436.35 cm 0 0 m 52.18 0 l S Q Q EMC BT /Span <>BDC 457.44 471.08 Td (, )Tj EMC /Span <>BDC 5.48 0 Td (copayment)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 445.36 436.35 cm 0 0 m 47.26 0 l S Q Q EMC BT /Span <>BDC 511.06 471.08 Td (, )Tj EMC /Span <>BDC (deductible)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 498.97 436.35 cm 0 0 m 43.98 0 l S Q Q EMC BT /Span <>BDC 561.39 471.08 Td (, )Tj EMC /Span <>BDC 5.48 0 Td (provider)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 549.31 436.35 cm 0 0 m 34.67 0 l S Q Q EMC BT /Span <>BDC 602.42 471.08 Td (, or other )Tj EMC /Span <>BDC 42.12 0 Td (underlined)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 626.98 436.35 cm 0 0 m 45.07 0 l S Q Q EMC BT /Span <>BDC 690.49 471.08 Td ( terms see the )Tj EMC /Span <>BDC -673.97 -13.77 Td (Glossary. 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)Tj EMC /Span <>BDC /TT2 12 Tf 23.05 7.01 Td ($1,700 Individual/ )Tj EMC /Span <>BDC 0 -13.77 TD ($3,400 Family )Tj EMC /Span <>BDC 94.5 13.77 Td ($3,400 Individual/ )Tj EMC /Span <>BDC T* ($6,800 Family )Tj EMC /Span <>BDC 94.5 13.77 Td (Generally, you must pay all of the costs from )Tj EMC /Span <>BDC 196.93 0 Td (providers)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 544.97 368.44 cm 0 0 m 39.59 0 l S Q Q EMC BT /Span <>BDC 603 403.17 Td ( up to the )Tj EMC /Span <>BDC 43.79 0 Td (deductible)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 629.22 368.44 cm 0 0 m 43.99 0 l S Q Q EMC BT /Span <>BDC 691.65 403.17 Td ( amount before this )Tj EMC /Span <>BDC -326.05 -13.77 Td (plan)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 348.04 354.67 cm 0 0 m 17.72 0 l S Q Q EMC BT /Span <>BDC 384.2 389.4 Td ( begins to pay. )Tj EMC /Span <>BDC /TT1 12 Tf -369.55 -32.82 Td (Are there services covered before )Tj EMC /Span <>BDC T* (you meet your )Tj EMC /Span <>BDC 70 0 Td (deductible)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 67.08 308.08 cm 0 0 m 48.34 0 l S Q Q EMC BT /Span <>BDC 133.86 342.81 Td (? )Tj EMC /Span <>BDC /TT2 12 Tf 42.74 13.9 Td (Yes. )Tj EMC /Span <>BDC 22.43 0 Td (Preventive care)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 181.47 321.98 cm 0 0 m 67.49 0 l S Q Q EMC BT /Span <>BDC 267.4 356.71 Td ( services are covered )Tj EMC /Span <>BDC -90.8 -13.77 Td (before you meet your )Tj EMC /Span <>BDC 95.74 0 Td (deductible)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 254.77 308.21 cm 0 0 m 43.99 0 l S Q Q EMC BT /Span <>BDC 317.2 342.94 Td (. )Tj EMC /Span <>BDC 48.4 27.54 Td (This )Tj EMC /Span <>BDC 21.33 0 Td (plan)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 369.37 335.75 cm 0 0 m 17.72 0 l S Q Q EMC BT /Span <>BDC 405.53 370.48 Td ( covers some items and services even if you haven\222t yet met the )Tj EMC /Span <>BDC 281.73 0 Td (deductible)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 669.7 335.75 cm 0 0 m 43.99 0 l S Q Q EMC BT /Span <>BDC 732.13 370.48 Td ( amount. )Tj EMC /Span <>BDC -366.53 -13.77 Td (But a )Tj EMC /Span <>BDC 25.72 0 Td (copayment)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 373.76 321.98 cm 0 0 m 47.26 0 l S Q Q EMC BT /Span <>BDC 439.46 356.71 Td ( or )Tj EMC /Span <>BDC 14.22 0 Td (coinsurance)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 436.12 321.98 cm 0 0 m 52.18 0 l S Q Q EMC BT /Span <>BDC 506.74 356.71 Td ( may apply. For example, this )Tj EMC /Span <>BDC 131.28 0 Td (plan)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 620.46 321.98 cm 0 0 m 17.72 0 l S Q Q EMC BT /Span <>BDC 656.62 356.71 Td ( covers certain )Tj EMC /Span <>BDC 66.74 0 Td (preventive )Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 705.79 321.98 cm 0 0 m 44.53 0 l S Q Q EMC BT /Span <>BDC 365.6 342.94 Td (services)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 348.04 308.21 cm 0 0 m 35.21 0 l S Q Q EMC BT /Span <>BDC 401.69 342.94 Td ( without )Tj EMC /Span <>BDC 36.65 0 Td (cost-sharing)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 420.78 308.21 cm 0 0 m 52.73 0 l S Q Q EMC BT /Span <>BDC 491.95 342.94 Td ( and before you meet your )Tj EMC /Span <>BDC 117.62 0 Td (deductible)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 592.01 308.21 cm 0 0 m 43.99 0 l S Q Q EMC BT /Span <>BDC 654.44 342.94 Td (. See a list of covered )Tj EMC /Span <>BDC -288.84 -13.77 Td (preventive services)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 348.04 294.44 cm 0 0 m 83.35 0 l S Q Q EMC BT /Span <>BDC 449.83 329.17 Td ( at \()Tj EMC /Span <>BDC 0 0 1 rg 16.96 0 Td (https://www.healthcare.gov/coverage/preventive-care-benefits/)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 1 RG 0.879 w 2 J q 1 0 0 1 449.23 294.44 cm 0 0 m 271.53 0 l S Q Q EMC BT /Span <>BDC 0 0 0 rg 739.2 329.17 Td (\). )Tj EMC /Span <>BDC /TT1 12 Tf -724.55 -17.97 Td (Are there other )Tj EMC /Span <>BDC 73.27 0 Td (deductibles)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 70.36 276.46 cm 0 0 m 53.8 0 l S Q Q EMC BT /Span <>BDC 142.6 311.2 Td ( for )Tj EMC /Span <>BDC -127.95 -13.78 Td (specific services? )Tj EMC /Span <>BDC /TT2 12 Tf 161.95 13.9 Td (No. )Tj EMC /Span <>BDC 189 -6.88 Td (You don\222t have to meet )Tj EMC /Span <>BDC 103.96 0 Td (deductibles)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 452 269.71 cm 0 0 m 48.9 0 l S Q Q EMC BT /Span <>BDC 519.34 304.44 Td ( for specific services. )Tj EMC /Span <>BDC /TT1 12 Tf -504.69 -26.46 Td (What is the )Tj EMC /Span <>BDC 55.23 0 Td (out-of-pocket limit)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 52.31 243.25 cm 0 0 m 84.95 0 l S Q Q EMC BT /Span <>BDC 155.7 277.98 Td ( for )Tj EMC /Span <>BDC -141.05 -13.77 Td (this )Tj EMC /Span <>BDC 20.23 0 Td (plan)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 17.32 229.48 cm 0 0 m 19.35 0 l S Q Q EMC BT /Span <>BDC 55.12 264.21 Td (? )Tj EMC /Span <>BDC /TT2 12 Tf -40.47 -13.64 Td (\(May include a )Tj EMC /Span <>BDC 66.73 0 Td (coinsurance )Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 63.82 215.84 cm 0 0 m 52.18 0 l S Q Q EMC BT /Span <>BDC 14.65 236.8 Td (maximum\) )Tj EMC /Span <>BDC 161.95 27.54 Td ($4,100 Individual/ )Tj EMC /Span <>BDC T* ($8,200 Family )Tj EMC /Span <>BDC 94.5 13.77 Td ($8,200 Individual/ )Tj EMC /Span <>BDC T* ($16,400 Family )Tj EMC /Span <>BDC 94.5 6.88 Td (The )Tj EMC /Span <>BDC 19.69 0 Td (out-of-pocket limit)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 367.73 222.72 cm 0 0 m 76.79 0 l S Q Q EMC BT /Span <>BDC 462.96 257.45 Td ( is the most you could pay in a year for covered services. )Tj EMC /Span <>BDC /TT1 12 Tf -448.31 -44.83 Td (What is not included in the )Tj EMC /Span <>BDC 127.95 0 Td (out)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 125.03 177.88 cm 0 0 m 14.42 0 l S Q Q EMC BT /Span <>BDC /TT1 10 Tf 157.89 212.62 Td (-)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 140.33 177.88 cm 0 0 m 1.85 0 l S Q Q EMC BT /Span <>BDC /TT1 12 Tf 160.62 212.62 Td (of)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 143.06 177.88 cm 0 0 m 8.41 0 l S Q Q EMC BT /Span <>BDC /TT1 10 Tf 169.91 212.62 Td (- )Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 152.35 177.88 cm 0 0 m 1.85 0 l S Q Q EMC BT /Span <>BDC /TT1 12 Tf 14.65 198.85 Td (pocket limit)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 -2.91 164.11 cm 0 0 m 53.81 0 l S Q Q EMC BT /Span <>BDC 69.34 198.85 Td (? )Tj EMC /Span <>BDC /TT2 12 Tf 107.26 20.78 Td (Premiums)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 159.04 184.9 cm 0 0 m 43.4 0 l S Q Q EMC BT /Span <>BDC 220.89 219.63 Td (, )Tj EMC /Span <>BDC (balance-billing)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 208.8 184.9 cm 0 0 m 62.02 0 l S Q Q EMC BT /Span <>BDC 289.26 219.63 Td ( charges, any )Tj EMC /Span <>BDC -112.66 -13.77 Td (pharmacy)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 159.04 171.13 cm 0 0 m 42.33 0 l S Q Q EMC BT /Span <>BDC 219.81 205.86 Td ( penalty and health care this )Tj EMC /Span <>BDC -43.21 -13.77 Td (plan)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 159.04 157.36 cm 0 0 m 17.72 0 l S Q Q EMC BT /Span <>BDC 195.2 192.09 Td ( doesn\222t cover. )Tj EMC /Span <>BDC 170.4 13.77 Td (Even though you pay these expenses, they don\222t count toward the )Tj EMC /Span <>BDC 290.54 0 Td (out\226of\226pocket limit)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 638.58 171.13 cm 0 0 m 81.18 0 l S Q Q EMC BT /Span <>BDC 738.2 205.86 Td (. )Tj EMC /Span <>BDC /TT1 12 Tf -723.55 -53.97 Td (Will you pay less if you use a )Tj EMC /Span <>BDC T* (network provider)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 -2.91 103.39 cm 0 0 m 78.95 0 l S Q Q EMC BT /Span <>BDC 94.48 138.12 Td (? )Tj EMC /Span <>BDC /TT2 12 Tf 82.12 20.78 Td (Yes. For a list of )Tj EMC /Span <>BDC 73.85 0 Td (network providers)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 232.88 124.17 cm 0 0 m 76.79 0 l S Q Q EMC BT /Span <>BDC 328.11 158.9 Td ( see )Tj EMC /Span <>BDC -151.51 -13.77 Td (\()Tj EMC /Span <>BDC 0 0 1 rg 3.28 0 Td (http://www.messa.org)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 1 RG 0.879 w 2 J q 1 0 0 1 162.31 110.4 cm 0 0 m 93.74 0 l S Q Q EMC BT /Span <>BDC 0 0 0 rg 274.49 145.13 Td (\) or call MESSA at )Tj EMC /Span <>BDC -97.89 -13.77 Td (800-336-0013)Tj EMC /Span <>BDC 189 41.31 Td (This )Tj EMC /Span <>BDC 21.33 0 Td (plan)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 369.37 137.94 cm 0 0 m 17.72 0 l S Q Q EMC BT /Span <>BDC 405.53 172.67 Td ( uses a )Tj EMC /Span <>BDC (provider)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 422.44 137.94 cm 0 0 m 34.67 0 l S Q Q EMC BT /Span <>BDC 475.55 172.67 Td ( )Tj EMC /Span <>BDC (network)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 460.73 137.94 cm 0 0 m 33.57 0 l S Q Q EMC BT /Span <>BDC 512.74 172.67 Td (. You will pay less if you use a )Tj EMC /Span <>BDC 134.03 0 Td (provider)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 629.21 137.94 cm 0 0 m 34.67 0 l S Q Q EMC BT /Span <>BDC 682.32 172.67 Td ( in the )Tj EMC /Span <>BDC (plan's )Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 694.3 137.94 cm 0 0 m 24.54 0 l S Q Q EMC BT /Span <>BDC 365.6 158.9 Td (network)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 348.04 124.17 cm 0 0 m 33.57 0 l S Q Q EMC BT /Span <>BDC 400.05 158.9 Td (. You will pay the most if you use an )Tj EMC /Span <>BDC 159.75 0 Td (out-of-network provider)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 542.24 124.17 cm 0 0 m 100.3 0 l S Q Q EMC BT /Span <>BDC 660.98 158.9 Td (, and you might receive a )Tj EMC /Span <>BDC -295.38 -13.77 Td (bill from a )Tj EMC /Span <>BDC 45.39 0 Td (provider)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 393.43 110.4 cm 0 0 m 34.67 0 l S Q Q EMC BT /Span <>BDC 446.54 145.13 Td ( for the difference between the )Tj EMC /Span <>BDC 135.69 0 Td (provider\222s)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 564.67 110.4 cm 0 0 m 41.77 0 l S Q Q EMC BT /Span <>BDC 624.88 145.13 Td ( charge and what your )Tj EMC /Span <>BDC 100.12 0 Td (plan)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 707.43 110.4 cm 0 0 m 17.73 0 l S Q Q EMC BT /Span <>BDC 743.6 145.13 Td ( pays )Tj EMC /Span <>BDC -378 -13.77 Td (\()Tj EMC /Span <>BDC 3.28 0 Td (balance billing)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 351.31 96.63 cm 0 0 m 61.49 0 l S Q Q EMC BT /Span <>BDC 431.24 131.36 Td (\). Be aware, your )Tj EMC /Span <>BDC 77.67 0 Td (network provider)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 491.35 96.63 cm 0 0 m 71.86 0 l S Q Q EMC BT /Span <>BDC 581.65 131.36 Td ( might use an )Tj EMC /Span <>BDC 61.82 0 Td (out-of-network provider)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 625.91 96.63 cm 0 0 m 100.3 0 l S Q Q EMC BT /Span <>BDC 744.65 131.36 Td ( for )Tj EMC /Span <>BDC -379.05 -13.77 Td (some services \(such as lab work\). Check with your )Tj EMC /Span <>BDC 223.69 0 Td (provider)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 571.73 82.86 cm 0 0 m 34.67 0 l S Q Q EMC BT /Span <>BDC 624.84 117.59 Td ( before you get services. )Tj EMC /Span <>BDC /TT1 12 Tf -610.19 -19.55 Td (Do you)Tj EMC /Span <>BDC 33.35 0 Td ( need a )Tj EMC /Span <>BDC 36.65 0 Td (referral)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 67.08 63.31 cm 0 0 m 33.03 0 l S Q Q EMC BT /Span <>BDC 118.55 98.04 Td ( to see a )Tj EMC /Span <>BDC -103.9 -13.77 Td (specialist)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 -2.91 49.54 cm 0 0 m 43.98 0 l S Q Q EMC BT /Span <>BDC 59.51 84.27 Td (? )Tj EMC /Span <>BDC /TT2 12 Tf 117.09 7.02 Td (No. )Tj EMC /Span <>BDC 189 0 Td (You can see the )Tj EMC /Span <>BDC 73.87 0 Td (specialist)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 421.91 56.56 cm 0 0 m 39.6 0 l S Q Q EMC BT /Span <>BDC 479.95 91.29 Td ( you choose without a )Tj EMC /Span <>BDC 97.93 0 Td (referral)Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0 0 0 RG 0.879 w 2 J q 1 0 0 1 560.32 56.56 cm 0 0 m 30.28 0 l S Q Q EMC BT /Span <>BDC 609.04 91.29 Td (. )Tj EMC ET /Artifact <>BDC q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 -4.8 419.44 cm 0 0 m 0 -372.21 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 157.15 419.44 cm 0 0 m 0 -160.24 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.25 w 2 J q 1 0 0 1 157.15 259.2 cm 0 0 m 0 -0.85 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 157.15 257.6 cm 0 0 m 0 -210.38 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 251.65 401.99 cm 0 0 m 0 -51.76 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 251.65 257.6 cm 0 0 m 0 -57.73 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 346.15 419.44 cm 0 0 m 0 -160.24 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.25 w 2 J q 1 0 0 1 346.15 259.2 cm 0 0 m 0 -0.85 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 346.15 257.6 cm 0 0 m 0 -210.38 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 760.05 419.44 cm 0 0 m 0 -372.21 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.5 w 2 J q 1 0 0 1 -4.93 419.69 cm 0 0 m 161.45 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.5 w 2 J q 1 0 0 1 157.02 419.69 cm 0 0 m 188.5 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.5 w 2 J q 1 0 0 1 346.02 419.69 cm 0 0 m 414.15 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 157.9 402.36 cm 0 0 m 187.5 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 -4.05 385.04 cm 0 0 m 763.35 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.25 w 2 J q 1 0 0 1 -4.3 350.1 cm 0 0 m 160.95 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.25 w 2 J q 1 0 0 1 157.65 350.1 cm 0 0 m 93.5 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.25 w 2 J q 1 0 0 1 251.4 350.1 cm 0 0 m 94.25 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.25 w 2 J q 1 0 0 1 346.65 350.1 cm 0 0 m 412.9 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.25 w 2 J q 1 0 0 1 -4.3 292.12 cm 0 0 m 160.95 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.25 w 2 J q 1 0 0 1 157.65 292.12 cm 0 0 m 188 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.25 w 2 J q 1 0 0 1 346.65 292.12 cm 0 0 m 412.9 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 -4.05 257.97 cm 0 0 m 763.35 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 -4.05 199.5 cm 0 0 m 763.35 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 -4.05 154.54 cm 0 0 m 763.35 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 -4.05 78.04 cm 0 0 m 763.35 0 l S Q Q q 1 0 0 1 18 33.02 cm 0.439 0.686 0.851 RG 0.75 w 2 J q 1 0 0 1 -4.8 46.85 cm 0 0 m 764.85 0 l S Q Q EMC Q endstream endobj 641 0 obj [643 0 R] endobj 642 0 obj <>stream H\j0 ~ Cqsl9MdE6sWqC '~K|0Ep%8oێ&*-pL dž U):+S1∔ :x1#ءqsܖPc)lh@UR5TRBrzc8]kvo+'߃g(;3Kd k!PQwo endstream endobj 643 0 obj <> endobj 644 0 obj <> endobj 645 0 obj <> endobj 646 0 obj <>stream Hj`0 endstream endobj 647 0 obj <>stream HV pTnB6 $[첁p% !.?$3  N!E'P`h)o  VvhgN¨Svf_:Nw=sw۽`E=7ԗֶnP־^$eesKK+66l}%wuB?I c$}Jc'zsShmpwO#39Di(?&em_XD u-֏]&NbU"!? 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