Atlantis Health Plan

SUMMARY OF COVERAGES Effective to 9/30/04 $347 single / $819 family
BENEFIT	IN-NETWORK	OUT-OF-NETWORK
Deductible single/family coinsurance maximum out of pocket(after ded) Lifetime maximum	$0 $0 $0 None	$1000/$2500 70/30 $3,000/$7,500 $1,000,000
Doctor Services
Of fice Visits ( PCP or Specialist) Inpatient Hospital visits Allergy testing & treatment Anethesia Diagnostic services and treatments Mamography screening Obstetrical/Gynecological services Pap smears Second surgical opinions periodic adult physical examinations Well child care visits(inc. immunizations) pre & post natal care delivery of child surgical services	$20 per visit no cost $20 per visit no cost $20 per visit $20 per visit $20 per visit $20 per visit no cost $20 per visit no cost $20 per visit no cost no cost	subject to deductible& coinsurance subject to deductible& coinsurance subject to deductible& coinsurance subject to deductible& coinsurance subject to deductible& coinsurance subject to deductible& coinsurance subject to deductible& coinsurance subject to deductible& coinsurance Atlantis pays 80% of UCR ratet in network benefit only in network benefit only subject to deductible& coinsurance subject to deductible& coinsurance subject to deductible& coinsurance
Ambulatory Services Radiation therapy & Chemotherapy X-ray & Laboratory services Hemodialysis pre admission testing	$20 copay per visit	Subject to deductible & coinsurance
Hospital Care
Inpatient admission (per continuous stay) Outpatient surgery facility charges blood and blood products ambulance service emergency room visit	$250 copay no cost no cost no cost $50 per visit	Subject to deductible & coinsurance Subject to deductible& coinsurance Subject to deductible& coinsurance Subject to deductible& coinsurance Subject to deductible& coinsurance
Hospital Alternatives
skilled nursing facility, 45 days per cal year home health care, 60 visits per cal year hospice cvare: Inpatient(210 days combined w/op) hospice care: outpatient	No cost no cost no cost no cost	subject to deductible & coinsurance subject to coinsurance only subject to deductible & coinsurance subject to deductible& coinsurance
Substance abuse
7 days inpatient detox per cal. year 60 outpatient rehab visits per cal. year (20 of the visits may be used for family therapy)	No cost $20 per visit	Atlantis pays 80% of UCR rate Subject to deductible & coinsurance Subject to deductible & coinsurance
Mental Health Care 30 days inpatient care per cal.year 20 outpatient visits per cal. year for Biologically based conditions	No cost $25 copay per visit	Atlantis pays 80% of UCR rate Outpatient - subject to deductible & coinsurance
Prescription Benefits /Eckerd Services
generic brand-formulary brand-non formulary	$20 $30 $40	Must use participating pharmacy
Chiropractic Care	$20 Copay per visit	Subject to deductible & 50% coinsurance $500 maximum payment per calendar year
Medical Equipment & Supplies Durable Equipment,medically necessary** Diabetic Equipment & supplies	No cost $20 per item or 34 day supply	Subject to deductible & coinsurance

Limitations and maximums are per Member per calendar year. Please Note : This sample summary of coverage is provided for information purposes only. The applicable summary of benefits will be issued to elligible enrolled members as part of the Subscriber Contract. Coverage is subject to the terms and conditions of the Subscriber Contract.