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<br />FEB:4-2002 09:43 FROM:BROWN & BROWN 305 B22 56B7 <br /> <br />TO:9P3059493113 <br /> <br />P:3/3 <br /> <br /> Aetna U.S. Healthcare <br /> USAccess Piau - Option 4 <br /> ~rida llt-Nawm; F10rida OId4N~rfc <br />FINA/VCIA.L ~ SdF-RdmaI Sdl'-RdCIftd <br />Deductible: SineIclFamily N/A. N/A SSOO/I. SO<> <br />Coi~ N/A NIl>.. io'~ <br />Coill!lA'anCe limit: Si~amily N1^ N1A ~s ,/)()QJS I 0.000 <br />Lif~me Ma:a/t1UlJl Bt!ncfil NtA. N1A $1,000.000 <br />PR.IMA/CY CARE PIUS/CIAN VISITS <br />Office Hour.; ~IO l:0piIy $:2 5 copay ?O"/. afler dcdlll;lible <br />I\fter Hwn .' H.xnc V illts $15 copay S2S~ 70% alkr d.roucliblc <br />SPECIAL 11' CAR,e <br />OffiQ: VisilS SIO oopsy S25~ ]0"/0 a.'icr lleclul:liblc <br />Dillgl105lic OUtpatieft\ T cSling $.\ 0 CCl\liIy !l2S copay 70% after dcd~ble <br />Phys.Occ.~h Thef\tpy SIO~ $25 cOIlI1Y 70% ;.ltc: deductible' <br />OIITPATIJ;NT SURGEII t ~ 1 00 copay uso copl\y 10".1. ~rdeductible' <br />HOS",ULIZA 77Q/V S240 cOlBY SSOO ~y 70% after dcduc:tiblc' <br />SKJLIA~D N(lRS1NG FACIUTY $:240 Cllp;\y ';500 copay 10"A. al'lcr dcd\J;!ible' <br />eMERGENCY ROOM 535 oopay $35 c~y 53 S copsy <br />IIOME Cdlt No cQpay I'll) <;Op8Y 70"~ after decluctiblc' <br />M..t TE/(JV'/TY <br />I'Il'!ilOBVi!lit $10 copay See mfCf1'ed caro iO% aftcr dW.udiblc' <br />Hosp;~l S240 ~y 1500 copay 70"/0 "ftcr ckductiblc' <br />MENTAL HEALTH <br />lntlilticnt (30 dayS) $;:40 cops~' $500 oopay 10% after deductible. <br />Outpat.m (20 v;51tsl S2S c~yN SZS cOfIaYN SO"!. afte! 6.dlo1C1iblc <br />SVIlST ANCE AB{J.fl! <br />Detoldfic8Iion S240.ccpay SSOO .copay 70% aft<< ded\leciblc. <br />(npatlml Rctbb,l;latian $~ro ~yl)O SSOQ copayf30 days 7<l".r. at\e\' deductibla.' <br /> d:lys per yest ~t YeN 30 days ~r )'$'l~ ' <br />Outpatiel1t RehabililtlUOCl S10 coply 30 $25 topayJ.44 lrisits 70% .ner deductible! <br /> visls per y...r per YCIIl 44 v;w ~ y....r ' <br />PREVE/V1TYft CARE <br />Routine E~e l!;l<i'Im S HhO?llY See ref~ care NQI ~avercd <br />ROUIine> PhysiCllI SIO copt.y S2, copay (lhtough 70%. no dedllCtible <br /> 8f,fl! 16 only) (through age 16 only) <br />IMmuni7.atioos (chil d hox1d 1 $10 copay S2S c~y (throtlfJ\ 'TOO/G. 110 deductible <br /> lIgt: 16 cnIy) (t~ age 16 only) <br />Itollline MammoBf;tplly SIO CWi1y $25 copay 70% after ~~\ib1e <br />RoutlllC (] YN ElW1l SIO copa~' See n:flmtld c~ Not cnW:~ <br />l'~dialn<: Prcvcmi\<e DcnlJlllj~ S 10 copay See n:fel'l'llld care !-lot covered <br />CHIROPRACTIC CARE SIO ~120 visit~ 525 ~yl 70% ,Ill;:r deductible! <br /> pcr~r Sloo0 1IIIIlIl811111L"1:' 5 1000 3M1.Il1.I ma."(' <br />/)ME /'10 c;opay No Cll\l8Y' 70",(, aftcr de4t,K:liOle' <br />PRESCRIPTIONS S I 011 500 Sce refe~ care IIIa'! e~vemd <br /> <br />. Member Dl'e'CI!11iIiOltiClllI'Cllllin!d qr beadllo peid ""II ~ ~li8l1y~. Tn TO<Civc _imum btftcfi"" In-l'fctwOllr. (rd'cmocfJ se....._ m\lSt be ptevided 01 <br />r1!~ by ~ peItlaplting ~ all': ~ !W 1AYc!lCfccmd. ID-Network (~ bc1lcfit:< om; pnMdccI by Iho AETI'oIA U.S. !1(~ I-lMO in ~ "'* <br />~Ir..rc~ belIcfits _ underwrilllCll!ly 11\ -... U.S. IiaiI1Ilcn at'filiated im;anmce O)mPl"l)'. All WnmtlIlR prIMded ill .-dance: \oid\ th;:, ;wIicablc IVOUP <br />llp~l. polley i1Ud CMi~, The cul~f-lltlWorlc coin_ ~.. rdte0 t~ p1"'1'~ p&yIIlelll. lo(MO(FL Opt 4 CI $.1 7 .,.l <br />