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Plan Name	PPO 90/50
Outpatient Services	In Network You Pay	Out of Network You Pay
Office Visits	$25	50%
Coinsurance	10%	50%
Emergency Room	$175	$175
Preventive Physicals	$25	50%
Wellness Services	$0	50%
Outpatient & Diagnostic testing	10%	50%
Surgeries/Procedures	10%	50%
Spinal Manipulations	50%	50%
Inpatient Services	In Network You Pay	Out of Network You Pay
Hospitalization	10%	50%
Extended Care/Rehabilitation	10%	50%
Mental Health Care	10%	50%
Substance Abuse Treatment	10%	50%
Resources
Print Application	Plan Policy
Evidence of Insurability Form	Provider Directory
Automatic Premium Payment Program Authorization Form	Exclusions and Limitations
Request Info Packet