Sala De Emergencia Códigos De Cubierta/Copagos

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SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA Enfermedad / Accidente CARACTERÍSTICAS CUBIERTA Enfermedad / Accidente CARACTERÍSTICAS A-01 A-02 n, A-03 n A-04 A-05 n A-06 l, n A-07 A-08 l, n A-09 A-10 n, A-11 m A-12 n A-13 b A-14 n A-15 ,n A-16 A, A-17 n, r A-18 n A-19 l, n A-20 n A-21 n A-22 A-23 A-24 l, n A-25 n A-26 l, n A-27 n, A-28 l, n A-29 l, n A-30 l, v A-31 l, n A-32 l, n A-33 n A-34 v A-35 n A-36 n A-37 n A-38 n A-39 l, n A-40 A-41 n A-42 A-43 n A-44 n A-45 n A-46 n, A-47 A-48 n A-49 l, n A-50 n A-51 m 50.00/ 25.00 40.00/NADA 25.00 55.00/NADA 20.00 20.00/NADA 5.00 20.00/NADA 50.00/ 25.00 50.00/NADA 50.00/ 15.00 20.00 25.00 20.00/NADA 20.00/ 20.00 50.00/ 20.00 40.00 / NADA 50.00 50.00/ 20.00 50.00 50.00/NADA @ @ @ @ @ @ @ @ @ @ @ @ A-52 n A-53 n A-54 l, n A-55 l, n A-56 l, n A-57 l, n A-58 A-59 l, n A-60 n A-61 l, n A-62 A-63 A-64 A-65 l, n A-66 m A-67 A-68 l, n A-69 n A-70 l n A-71 m A-72 l, n A-73 l, n A-74 l, n A-75 n A-76 v A-77 l, n A-78 n A-79 n A-80 n A-81 m A-82 l, n A-83 n A-84 n A-85 l, n A-86 n A-87 A-88 l, n A-89 v A-90 A-91 v A-92 v A-93 v A-94 n A-95 n A-96 l, n A-97 n A-98 l, v A-99 v AA-01 n, AA-02 l, n AA-03 n 75.00 20.00 20.00/NADA 10.00/NADA 35.00//NADA 30.00/NADA * 20.00/NADA 50.00 25.00//NADA * * * 25.00/NADA 75.00/ 50.00 NADA 50.00/NADA 20.00 20.00/NADA 50.00/ 25.00 10.00/NADA 35.00/NADA 10.00/NADA 20.00 20.00/NADA 20.00/NADA 10.00 10.00 50.00 50.00/ 25.00 10.00/NADA 20.00 100.00/NADA 50.00/NADA 20.00 * 50.00/ 25.00 25.00//NADA * 50.00/ 50.00 20.00//NADA 50.00/ 50.00 50.00 5.00 25.00/NADA 10.00 10.00/NADA 20.00/NADA 75.00/NADA 55.00/ 55.00 5.00 @ @ @ @ @ @ * @ @ @ * * * @ @ @ @ @ @ @ @ @ @ @ @ @ t @ * @ @ @ @ @ @ * @ @ * @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ 125.00/ 75.00 @ 125.00/ 75.00 @ 25.00/NADA @ 20.00 @ 80.00/NADA @ 50.00/ 50.00 @ 30.00/NADA @ 50.00/NADA @ 35.00/NADA @ 25.00/NADA @ 25.00/NADA @ 50.00/NADA @ 20.00 @ 20.00 @ 50.00 @ 40.00/NADA @ 20.00 @ 20.00/NADA @ * * 25.00 @ * * 50.00/ 20.00 @ 50.00 @ 20.00/NADA @ 150.00/ 50.00 @ * * 20.00 @ 20.00/NADA @ 20.00 @ 50.00/ 25.00 @ 1 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA Enfermedad / Accidente CARACTERÍSTICAS CUBIERTA Enfermedad / Accidente CARACTERÍSTICAS AA-04 n AA-05 n AA-06 n AA-07 l, n AA-08 m AA-09 n AA-10 AA-11 l,v AA-12 AA-13 l, n AA-14 , n AA-15 l, v AA-16 n AA-17 l, n AA-18 n AA-19 AA-20 AA-21 n AA-22 n AA-23 n AA-24 l, n AA-25 n AA-26 , n AA-27 v AA-28 n AA-29 n AA-30 n AA-31 n AA-32 n AA-33 n AA-34 AA-35 n AA-36 n AA-37 AA-38 n AA-39 AA-40 n AA-41 l, n AA-42 n AA-43 AA-44 n AA-45 l, n AA-46 n AA-47 n AA-48 AA-49 n AA-50 n AA-51 n AA-52 n AA-53 l, n 40.00/NADA 25.00 50.00/NADA 50.00/NADA 50.00 40.00/NADA 20.00/ 20.00 25.00/NADA 30.00/NADA 50.00/NADA 50.00/NADA 15.00/NADA 50.00 35.00/NADA 30.00 50.00/ 25.00 NADA 20.00 20.00 35.00 50.00/NADA 20.00 20.00/NADA 25.00 10.00 50.00 25.00 25.00 20.00 50.00 * 10.00/ NADA 30.00 50.00/NADA 75.00 * 10.00 30.00/NADA 30.00 * 35.00 30.00/NADA 50.00 20.00 * 20.00 25.00 20.00 20.00 25.00/NADA @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ * @ @ @ @ * @ @ @ * @ @ @ @ * @ @ @ @ @ AA-55 n AA-56 n AA-57 x AA-58 n AA-59 m AA-60 n, AA-61 AA-62 n, AA-63 l, n, AA-64 l, n AA-65 n AA-66 l, n, AA-67 m AA-68 l, n AA-69 l, n AA-70 n, AA-71 n AA-72 l, n AA-73 n AA-74 m AA-75 n AA-76 l, n AA-77 n AA-78 n AA-79 n AA-80 n AA-81 n AA-82 l, n AA-83 n AA-84 AA-85 n AA-86 n AA-87 l, n AA-88 m AA-89 m AA-90 l, n AA-91 l, n AA-92 n, AA-93 n AA-94 l, n, AA-95 n AA-96 n AA-97 n AA-98 m AA-99 l, n AB-01 n AB-02 l, o AB-03 AB-04 n AB-05 n 10.00 50.00/ NADA 15.00 50.00 75.00/ 35.00 25.00/NADA 125.00 50.00 40.00/ 40.00 35.00/NADA 50.00 50.00/NADA 75.00 50.00/ 10.00 50.00/NADA 25.00/ 25.00 30.00 10.00/NADA 50.00 50.00 50.00/ 50.00 50.00/NADA 20.00 20.00 25.00 25.00 50.00 50.00/NADA 20.00 @ @ @ @ @ @ * @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ * @ @ 2 125.00/ 75.00 20.00 50.00 35.00/NADA 75.00 75.00 50.00/NADA 15.00/NADA 75.00/NADA 25.00 75.00/NADA 10.00 20.00 35.00 50.00 50.00/NADA 20.00 75.00/NADA 125.00 35.00/NADA 75.00 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS AA-54 l, n 50.00/NADA @ AB-06 n 3 10.00 @ 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA Enfermedad / Accidente CARACTERÍSTICAS CUBIERTA Enfermedad / Accidente CARACTERÍSTICAS AB-07 n AB-08 o AB-09 n AB-10 n AB-11 l, n AB-12 o AB-13 o AB-14 o AB-15 AB-16 AB-17 n AB-18 o AB-19 l, n AB-20 n AB-21 AB-22 o AB-23 AB-24 l, n AB-25 l, n AB-26 AB-27 AB-28 l, n AB-29 l, n AB-30 n AB-31 AB-32 n, AB-33 l, n AB-34 l, n AB-35 l,n AB-36 n, AB-37 n AB-38 o AB-39 l, n AB-40 l, n AB-41 l, n AB-42 n AB-43 n AB-44 l, n AB-45 n, AB-46 n AB-47 l, n AB-48 l, n AB-49 l, n AB-50 n AB-51 n AB-52 n, ll AB-53 n AB-54 n AB-55 y AB-56 n AB-57 n, 50.00 50.00 75.00/ 75.00 50.00/ 50.00 50.00/ 50.00 50.00 50.00 20.00 25.00 25.00/NADA 20.00 50.00 25.00/NADA 50.00 * 50.00 * 50.00/NADA 50.00/NADA 20.00/NADA * 20.00/NADA 20.00/NADA 50.00 * 55.00/NADA 25.00/NADA 35.00/NADA 25.00/NADA 45.00/NADA 10.00 75.00/NADA 20.00/NADA 50.00/NADA 20.00/NADA 35.00 25.00 100/ 50 35.00/NADA 50.00 20.00/NADA 20.00/NADA 25.00/NADA 50.00 20.00 50.00/NADA 25.00 5.00 125.00 20.00 40.00/NADA @ @ @ @ @ @ @ * @ @ @ * * @ * @ * @ @ @ * @ @ @ * @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ AB-58 n AB-59 AB-60 l, n AB-61 l, n AB-62 n, AB-63 b AB-64 AB-65 n AB-66 l, n AB-67 n, AB-68 n AB-69 n, AB-70 l, n AB-71 ,n AB-72 b AB-73 n AB-74 n AB-75 l, n AB-76 ,n AB-77 l, n AB-78 n AB-79 n AB-80 l, n AB-81 l, n AB-82 m AB-83 ,n AB-84 AB-85 l, n AB-86 l, n AB-87 m AB-88 l, n AB-89 o, AB-90 n, AB-91 n, AB-92 AB-93 n AB-94 n, AB-95 l, n AB-96 ll AB-97 n AB-98 ,n AB-99 y AC-01 b AC-02 z AC-03 z AC-04 n AC-05 n AC-06 AC-07 AC-08 v AC-09 n 50.00 * 50.00/ 25.00 50.00/ 25.00 40.00/NADA 25.00 25.00/ NADA 30.00 10.00/NADA 50.00/NADA 25.00 40.00/NADA 10.00/NADA 50.00/NADA 25.00 20.00 30.00 10.00/NADA 50.00/NADA 35.00/NADA 20.00 35.00 40.00/20.00 50.00/NADA 50.00 NADA/NADA 30.00/NADA 10.00/NADA 30.00/NADA 50.00 50.00/NADA 25.00/NADA 40.00/NADA 40.00/NADA * 50.00 20.00 20.00/NADA 50.00/NADA 50.00 40.00/NADA 100.00/NADA NADA 75.00/NADA 75.00/NADA 50.00 30.00 125.00/NADA * 10.00 25.00 @ * @ @ @ 4 @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ * @ @ @ @ @ @ @ @ @ @ @ @ * @ @ 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS 5 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA Enfermedad / Accidente CARACTERÍSTICAS CUBIERTA Enfermedad / Accidente CARACTERÍSTICAS AC-10 n AC-11 l, v, AC-12 l, n AC-13 l, n AC-14 n AC-15 m AC-16 m AC-17 AC-18 n AC-19 AC-20 n AC-21 n AC-22 n AC-23 n AC-24 n AC-25 n AC-26 AC-27 AC-28 AC-29 AC-30 AC-31 AC-32 l, n AC-33 AC-34 AC-35 n AC-36 n AC-37 n AC-38 l, n AC-39 n AC-40 l, n AC-41 AC-42 z AC-43 AC-44 n AC-45 AC-46 AC-47 l, n AC-48 n AC-49 b AC-50 n AC-51 n, AC-52 n, AC-53 n, AC-54 l, n AC-55n, AC-56 n AC-57n 20.00 40.00/ 40.00 20.00/NADA 35.00/NADA 50.00 50.00 50.00 * 20.00 20.00 20.00 20.00 20.00 20.00 20.00 20.00 * * * * * * 20.00/NADA * * 50.00 20.00/NADA 30.00 15.00/NADA 20.00 20.00/NADA * 75.00/NADA * 40.00 * * 50.00/NADA 20.00 25.00 20.00 55.00/NADA 45.00/NADA 35.00/NADA 15.00/NADA 40.00/NADA 30.00 20.00/NADA @ @ @ @ @ @ @ * @ * @ @ @ @ @ @ * * * * * * @ * * @ @ @ @ @ @ * @ * @ * * @ @ AC-58 n AC-59 l, n AC-60 n, AC-61 n AC-62 AC-63 l, v AC-64 l, n AC-65 l, n AC-66 l, n AC-67 n AC-68 AC-69 n AC-70 n, AC-71 n, AC-72 n AC-73 l, n AC-74 n, AC-75 , n AC-76 l, n AC-77 n AC-78 , AC-79 n AC-80 n AC-81 l, n AC-82 n AC-83 n AC-84 , v AC-85 l, n, AC-86 ,n AC-87 n AC-88 n AC-89 n AC-90 l, n AC-91 AC-92 n AC-93 b AC-94 n AC-95 ,n AC-96 n AC-97 l, v AC-98 ,n AC-99 l, n AD-18 n AD-19 n AD-20 n AD-21 l, n AD-22 l, n AD-23 n 20.00 20.00/NADA 60.00/NADA 20.00 * 25.00/NADA 25.00/NADA 35.00/NADA 50.00/NADA 50.00 * 20.00 55.00/NADA 45.00/NADA 20.00 25.00/NADA 35.00/NADA 40.00/NADA 25.00/NADA 50.00/ 25.00 50.00/NADA 50.00 40.00 5.00/NADA 50.00 20.00 40.00/NADA 10.00/NADA 75.00/NADA 25.00 35.00 50.00/NADA 35.00/NADA NADA 50.00 25.00 20.00 75.00/NADA 50.00 15.00/NADA 50.00/NADA 50.00/NADA 25.00 75.00 30.00 10.00/NADA 30.00/NADA 50.00 @ @ @ @ * @ @ @ @ @ * @ @ @ @ @ @ @ @ @ * @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ 6 @ @ @ @ @ @ @ @ @ @ @ @ 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS 7 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA Enfermedad / Accidente CARACTERÍSTICAS CUBIERTA Enfermedad / Accidente CARACTERÍSTICAS AD-24 l, n AD-25 n AD-26 n AD-27 l, n AD-28 n AD-29 l, n AD-30 l, n AD-31 l, o AD-32 n AD-33 l, n AD-34 l, n AD-35 l, n AD-36 b AD-37 b AD-38 b AD-39 b AD-40 , n AD-41 n AD-42 b AD-43 n AD-44 , o AD-45 n AD-46 n AD-47 l, n AD-48 AD-49 n AD-50 m AD-51 n AD-52 n AD-53 l, n AD-54 n AD-55 l, v AD-56 l, v AD-57 o AD-58 o, AD-59 n AD-60 n AD-61 n, AD-62 l, n AD-63 AD-64 n AD-65 m AD-66 AD-67 AD-68 m AD-69 n AD-70 l, m 40.00 50.00 35.00 35.00/NADA 50.00 35.00/NADA 50.00/NADA 50.00/NADA 30.00 25.00/NADA 25.00/NADA 30.00/NADA NADA 1.00 2.00 5.00 40.00/NADA 25.00 25.00 35.00 75.00/ 25.00 50.00 35.00/NADA 10.00/NADA * 25.00/NADA 50.00 20.00 10.00 50.00/NADA 20.00 20.00/NADA 20.00/NADA 50.00 75.00/ 30.00 10.00 40.00 20.00/NADA 40.00/NADA * 40.00/NADA 75.00 * * 50.00 50.00 30.00/ 10.00 @ @ @ @ @ @ @ @ @ @ @ @ AD-71 l, n AD-72 l, n AD-73 l, n AD-74 c, l AD-75 l, n AD-76 n AD-77 l AD-78 l, n AD-79 AD-80 l, n AD-81 n, AD-82 n AD-83 n, AD-84 n AD-85 AD-86 l, n AD-87 l, n AD-88 l, n AD-89 l, n AD-90 n AD-91 l, n AD-92 AD-93 m AD-94 m AD-95 n AD-96 m AD-97 l, n AD-98 l, c AD-99 b AE-01 n AE-02 AE-03 n AE-04 AE-05 n AE-06 m AE-07 m AE-08 AE-09 AE-10 AE-11 AE-12 AE-13 B AE-14 n AE-15 l, n AE-16 n AE-17 n AE-18 n 35.00/NADA 50.00/NADA 30.00/NADA 50.00/NADA 50.00/NADA 50.00 50.00 20.00/NADA * 35.00/NADA 20.00/ 20.00 20.00 35.00/NADA 50.00 * 50.00/NADA 50.00/NADA 50.00/NADA 35.00/NADA 20.00 50.00/NADA * 50.00 50.00 50.00 50.00 25.00/NADA 50.00/NADA 25.00 20.00 55.00/NADA 75.00 55.00/NADA 50.00/NADA 75.00/ 25.00 100.00 * * 75.00/ 50.00 40.00/NADA * 25.00/NADA 50.00 30.00/NADA 50.00/ 50.00 10.00 10.00 @ @ @ @ @ @ @ @ @ @ * @ @ @ @ @ @ @ @ @ @ @ @ @ @ * @ @ * * @ @ @ 8 @ @ @ @ * @ @ @ @ @ * @ @ @ @ @ @ * @ @ @ @ @ @ @ @ @ @ @ @ @ * * @ * @ @ @ @ @ @ 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA Enfermedad / CARACTERÍSTICAS Accidente CUBIERTA Enfermedad / Accidente AE-19 n AE-20 n AE-21 n AE-22 AE-23 n AE-24 AE-25 AE-26 l, n, AE-27 n AE-28 l, n AE-29 AE-30 m AE-31 l, n AE-32 n AE-33 AE-34 n AE-35 n AE-36 l, n AE-37 ,z AE-38 l, n AE-39 l, o AE-40 l, n AE-41 l, n AE-42 , z AE-43 n AE-44 AE-45 AE-46 n AE-47 n AE-48 n AE-49 l, x AE-50 l, x AE-51 , z AE-52 n AE-53 l, n AE-54 AE-55 l, n AE-56 ,n AE-57 o, m, l AE-58 ,n AE-59 n AE-60 AE-61 m AE-62 15.00 15.00 15.00 * 40.00 50.00/ 25.00 50.00 50.00/ 25.00 50.00 25.00/NADA 100.00 50.00/ 25.00 75.00/ 50.00 40.00 50.00 30.00 30.00 50.00/NADA 75.00/NADA 50.00/NADA 125.00/25.00 25.00/NADA 50.00/NADA 75.00/NADA 35.00 125.00 * 35.00 50.00 25.00 40.00/NADA 30.00/NADA 70.00/NADA 50.00/NADA 10.00/NADA * 25.00/NADA 75.00/ 75.00 100.00/50.00 75.00/ 75.00 40.00/NADA * 75.00 * AE-63 AE-64 m AE-65 m AE-66 n AE-67 AE-68 n, AE-69 n AE-70 m AE-71 n AE-72 ,n AE-73 ,n AE-74 m AE-75 AE-76 l, n AE-77 l, n AE-78 l, n AE-79 l, o AE-80 n AE-81 n AE-82 b AE-83 m AE-84 AE-85 b AE-86 n AE-87 n, AE-88 AE-89 n AE-90 l, n AE-91 n AE-92 n AE-93 n AE-94 n AE-95 l, n AE-96 AE-97 n AE-98 n AE-99 AF-01 n AF-02 v AF-03 n AF-04 o, AF-05 l, n AF-06 AF-07 l, o 25.00 50.00 50.00 35.00 NADA 50.00 20.00 50.00 30.00 50.00/NADA 50.00/ 50.00 50.00/25.00 50.00 25.00/NADA 75.00/NADA 50.00/NADA 50.00/NADA 75.00 50.00 25.00 100.00 * NADA 75.00 50.00/NADA 25.00 50.00 50.00/20.00 25.00 50.00 25.00 75.00 30.00/NADA NADA 25.00 20.00 50.00/NADA 50.00 80% 20.00 50.00/ 50.00 50.00/NADA * 45.00/NADA @ @ @ * @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ * @ @ @ @ @ @ @ @ * @ @ @ @ @ * @ 9 CARACTERÍSTICAS @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ * @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ * @ 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA AF-08 l, n AF-09 l, n AF-10 l, n AF-11 l, n AF-12 n AF-13 n AF-14 n AF-15 l, n AF-16 l, n AF-17 n AF-18 AF-19 m AF-20 m AF-21 m AF-22 m AF-23 l, n AF-24 l, n AF-25 l, n AF-26 l, n AF-27 l, o AF-28 l, n AF-29 l, n AF-30 AF-31 n AF-32 n AF-33 n AF-34 l, n AF-35 n AF-36 c, l AF-37 n AF-38 AF-39 AF-40 l, n, AF-41 l, n AF-42 AF-43 AF-44 AF-45 AF-46 AF-47 AF-48 AF-49 AF-50 AF-51 AF-52 AF-53 A Enfermedad / Accidente 75.00/25.00 50.00/25.00 50.00/25.00 35.00/NADA 25.00 50.00 25.00 35.00/NADA 25.00/NADA 50.00 * 50.00 50.00 75.00 75.00 50.00/NADA 50.00/NADA 100.00/50.00 75.00/ 25.00 50.00/NADA 50.00/NADA 50.00/ 25.00 * 35.00 50.00 30.00 25.00/NADA 50.00 50.00/ 20.00 50.00 * * 35.00/NADA 50.00/NADA * 75.00 75.00 45.00/ 45.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 55.00/ 55.00 CARACTERÍSTICAS CUBIERTA @ @ @ @ @ @ @ @ @ @ * @ @ @ @ @ @ @ @ @ @ @ * @ @ @ @ @ @ @ * * @ @ * * * @ * * * * * * * @ AF-54 AF-55 AF-56 AF-57 v AF-58 AF-59 n AF-60 AF-61 m AF-62 AF-63 n AF-64 l, v AF-65 n AF-66 l, n AF-67 o, l AF-68 AF-69 l, n AF-70 AF-71 AF-72 AF-73 AF-74 AF-75 AF-76 AF-77 AF-78 AF-79 AF-80 AF-81 AF-82 AF-83 AF-84 AF-85 AF-86 n AF-87 AF-88 n AF-89 AF-90 AF-91 AF-92 m AF-93 AF-94 n AF-95 AF-96 l, n AF-97 n AF-98 l, n AF-99 n 10 Enfermedad / Accidente 50.00/NADA 25.00/NADA 50.00/25.00 35.00/NADA 50.00/25.00 30.00 * 75.00 75.00/NADA 75.00 40.00/NADA 40.00 50.00/NADA 50.00/25.00 75.00/NADA 40.00/NADA * * * * * * * * * * * * * * * * 25.00/ 25.00 * 75.00 * * * 50.00 * 50.00 20.00 50.00/NADA 50.00 35.00/NADA 20.00 CARACTERÍSTICAS @ @ @ @ @ @ * @ @ @ @ * @ @ @ @ * * * * * * * * * * * * * * * * @ * @ * * * @ * @ @ @ @ @ @ 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA AG-01 m AG-02 AG-03 m AG-04 n AG-05 m AG-06 l, n AG-07 n AG-08 n AG-09 AG-10 AG-11 AG-12 l, n AG-13 n, AG-14 n AG-15 l, n AG-16 m AG-17 n AG-18 n AG-19 l, n AG-20 n AG-21 l, n AG-22 m AG-23 n AG-24 m AG-25 n AG-26 n AG-27 n AG-28 n AG-29 l, n AG-30 n AG-31 l, n AG-32 l, n AG-33 n AG-34 n, AG-35 n AG-36 n, AG-37 o AG-38 l, n AG-39 AG-40 n AG-41 n AG-42 l, o AG-43 m AG-44 l, n AG-45 l, n AG-46 m Enfermedad / Accidente 50.00 35.00 50.00 30.00 50.00/ 25.00 75.00/ 50.00 45.00 25.00/NADA 25.00 75.00/NADA 45.00 50.00/NADA 40.00/NADA 500.00 50.00/NADA 50.00 35.00 75.00/ 50.00 50.00/NADA 40.00/NADA 35.00/NADA 50.00 20.00 50.00 20.00 20.00 20.00 50.00/ 25.00 5.00/ 75.00 50.00 50.00/NADA 50.00/NADA 20.00 35.00 50.00 40.00 50.00 25.00/NADA 40.00/NADA 50.00 20.00 50.00/NADA 50.00 50.00/NADA 35.00/NADA 50.00 CARACTERÍSTICAS CUBIERTA @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ AG-47 n AG-48 n AG-49 l, n AG-50 l, n AG-51 n AG-52 l, n AG-53 m AG-54 l, n AG-55 n AG-56 l, n AG-57 AG-58 l, n AG-59 n AG-60 n AG-61 AG-62 l, n AG-63 n AG-64 AG-65 o AG-66 AG-67 o AG-68 B AG-69 l, n AG-70 AG-71 l, n AG-72 l, n AG-73 n AG-74 n AG-75 AG-76 n AG-77 AG-78 l, n AG-79 n AG-80 n AG-81 n AG-82 l, n AG-83 n AG-84 n AG-85 n AG-86 l, n AG-87 o AG-88 o AG-89 o AG-90 n AG-91 o AG-92 n 11 Enfermedad / Accidente 20.00 20.00 50.00/NADA 20.00/NADA 50.00 50.00/NADA 50.00 30.00/NADA 40.00 20.00/NADA * 15.00/NADA 20.00 20.00 20.00/NADA 50.00/NADA 20.00 50.00/NADA 50.00 30.00 50.00/NADA 50.00/ 25.00 50.00/ 20.00 75.00/ 50.00 50.00/ 25.00 50.00/ 25.00 20.00 50.00 50.00 50.00 75.00 50.00/ 25.00 35.00 50.00 20.00 35.00/NADA 50.00 50.00/NADA 50.00 75.00/ 75.00 50.00 50.00 50.00 20.00 50.00 50.00/ 50.00 CARACTERÍSTICAS @ @ @ @ @ @ @ @ @ @ * @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA AG-93 AG-94 o AG-95 AG-96 l, n AG-97 n AG-98 AG-99 l,n AH-01 l, n AH-02 n AH-03 l, n AH-04 l, n AH-05 n AH-06 n, AH-07 n, AH-08 y, AH-09 l, n AH-10 n AH-11 n AH-12 AH-13 l, n AH-14 n AH-15 n AH-16 lll AH-17 n AH-18 n AH-19 n AH-20 n AH-21 n AH-22 n AH-23 n AH-24 o AH-25 n AH-26 o AH-27 o AH-28 o AH-29 n AH-30 n AH-31 o AH-32 n AH-33 n AH-34 o, AH-35 o AH-36 o AH-37 n AH-38 AH-39 o Enfermedad / Accidente 50.00/NADA 50.00/ 25.00 CARACTERÍSTICAS @ 100.00/ 100.00 75.00/ 75.00 20.00 50.00 20.00/NADA 50.00/NADA 50.00 40.00/NADA 50.00/ 25.00 20.00 50.00/NADA 50.00/NADA 125.00 50.00/NADA 20.00 40.00 75.00 50.00/NADA 50.00 20.00/NADA 50.00/ 50.00 50.00/NADA 75.00/ 75.00 25.00/NADA 50.00 30.00 50.00/ 50.00 50.00 20.00/ 20.00 75.00/ 75.00 50.00/NADA 75.00/NADA 20.00/NADA 20.00 75.00/ 75.00 100.00/50.00 50.00/ 50.00 50.00/ 50.00 75.00/NADA 75.00/NADA 40.00/ 40.00 50.00/NADA 75.00/NADA 75.00/ 20.00 @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ CUBIERTA AH-40 n AH-41 n AH-42 l, n AH-43 AH-44 n AH-45 l, q AH-46 ,o AH-47 o AH-48 n AH-49 n AH-50 n AH-51 n AH-52 o AH-53 AH-54 n AH-55 n AH-56 AH-57 AH-58 n AH-59 AH-60 n AH-61 l, n AH-62 n AH-63 n AH-64 l, n AH-65 l, n AH-66 n AH-67 l, n AH-68 n AH-69 n AH-70 n AH-71 n AH-72 n AH-73 AH-74 l, n AH-75 l, n AH-76 n AH-77 l, n AH-78 l, n AH-79 n AH-80 n AH-81 n AH-82 n AH-83 AH-84 n AH-85 n 12 Enfermedad / Accidente 75.00/ 20.00 50.00 50.00/NADA 40.00/NADA 50.00/NADA 75.00/NADA 45.00/NADA 50.00/ 25.00 35.00/NADA 40.00/NADA 40.00/NADA 40.00/NADA 35.00/NADA 50.00/ 25.00 25.00 50.00/NADA 5.00 30.00/NADA 50.00/NADA N/C 75.00 75.00 75.00 75.00/ 25.00 25.00 30.00/NADA 75.00/ 25.00 50.00/NADA 50.00 20.00 50.00 35.00 75.00 100.00/NADA 75.00 50.00/NADA 20.00 25.00/NADA 30.00/NADA 50.00 75.00/ 75.00 75.00/ 75.00 50.00/ 50.00 N/C 75.00/ 25.00 100.00/ 25.00 CARACTERÍSTICAS @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ * @ * @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ * @ @ 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA AH-86 n AH-87 n AH-88 n AH-89 n AH-90 n AH-91 n AH-92 n AH-93 AH-94 n AH-95 n AH-96 III AH-97 n AH-98 n AH-99 n AI-01 n AI-02 n AI-03 o AI-04 n AI-05 AI-06 n AI-07 v AI-08 n AI-09 n AI-10 n AI-11 n AI-12 n AI-13 n AI-14 n AI-15 v AI-16 n AI-17 AI-18 n AI-19 AI-20 n AI-21 AI-22 o AI-23 II AI-24 n AI-25 II AI-26 n AI-27 n AI-28 v AI-29 AI-30 AI-31 l, n AI-32 n Enfermedad / Accidente 125.00/ 25.00 75.00 30.00/ 30.00 40.00/NADA 25.00 50.00/NADA 50.00/NADA 25.00 50.00/ 50.00 35.00/NADA 20.00 20.00/ 50.00 40.00/NADA 30.00/NADA 30.00/NADA 25.00/NADA 50.00 100/ 50.00 25.00 50.00/NADA 20.00/NADA 50.00/NADA 20.00 25.00/NADA 40.00/ 40.00 35.00/NADA 50.00/NADA 25.00 60.00/NADA 30.00/NADA 20.00 25.00/NADA 50.00/NADA 20.00 35.00/NADA 50.00/NADA 75.00/ 75.00 50.00 75.00/ 75.00 75.00/NADA 50.00/NADA 10.00/NADA 20.00/NADA 25.00 75.00 100.00 CARACTERÍSTICAS CUBIERTA @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ AI-33 n AI-34 n AI-35 n AI-36 n AI-37 o AI-38 n AI-39 n AI-40 n AI-41 n AI-42 n AI-43 n AI-44 n AI-45 o AI-46 o AI-47 n AI-48 n, AI-49 ,lll AI-50 AI-51 AI-52 AI-53 AI-54 AI-55 AI-56 AI-57 AI-58 AI-59 n AI-60 AI-61 AI-62 n AI-63 AI-64 AI-65 n AI-66 n AI-67 z AI-68 n AI-69 AI-70 lll AI-71 AI-72 AI-73 AI-74 AI-75 AI-76 AI-77 AI-78 13 Enfermedad / Accidente 35.00/NADA 50.00/ 25.00 20.00 20.00 45.00/NADA 100.00 50.00 50.00 45.00/NADA 50.00 50.00/NADA 50.00/ 20.00 45.00/NADA 45.00/NADA 20.00/NADA 20.00 40.00/NADA 40.00/ 20.00 * * 20.00 * * * * * 50.00/NADA * * 35.00/NADA * 50.00/NADA 35.00 20.00 75.00/ 50.00 50.00/NADA 40.00/NADA 40.00/NADA * * * * * * * * CARACTERÍSTICAS @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ * * @ * * * * * @ * * @ * @ @ @ @ @ @ @ * * * * * * * * 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA AI-79 AI-80 AI-81 AI-82 AI-83 AI-84 AI-85 AI-86 AI-87 n AI-88 n AI-89 n AI-90 AI-91 n AI-92 n AI-93 n AI-94 n AI-95 AI-96 n AI-97 n AI-98 n AI-99 n AL-01 n AL-02 l, o AL-03 l, o AL-04 l, o AL-05 AL-06 AL-07 AL-08 o AL-09 AL-10 AL-11 AL-12 AL-13 AL-14 AL-15 l AL-16 l AL-17 l AL-18 o AL-19 AL-20 n AL-21 n AL-22 n AL-23 n AL-24 z AL-25 B Enfermedad / Accidente * * * * * 20.00/NADA * * 25.00 50.00/NADA 20.00 NADA 50.00/NADA 25.00/NADA 30.00/NADA 20.00 80.00/NADA 75.00/NADA 75.00/NADA 75.00/NADA 35.00/NADA 40.00 75.00/NADA 50.00/NADA 50.00/NADA 75.00/ 35.00 75.00/ 35.00 50.00/ 25.00 50.00 20.00 50.00/ 25.00 50.00/ 25.00 50.00/ 25.00 50.00/ 25.00 50.00/ 25.00 100.00/ 50.00 75.00/ 25.00 50.00/NADA 50.00/ 25.00 50.00/ 25.00 50.00/NADA 50.00/NADA 50.00/NADA 30.00 75.00 25.00 CARACTERÍSTICAS CUBIERTA * * * * * @ * * @ @ @ @ @ @ @ @ * @ @ @ @ @ @ @ @ * @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ AL-26 n AL-27 n AL-28 n AL-29 n AL-30 n AL-31 n AL-32 n AL-33 n AL-34 n AL-35 n AL-36 AL-37 AL-38 AL-39 AL-40 AL-41 AL-42 AL-43 AL-44 AL-45 AL-46 AL-47 AL-48 AL-49 AL-50 AL-51 AL-52 AL-53 AL-54 o AL-55 AL-56 AL-57 AL-58 o AL-59 AL-60 AL-61 AL-62 AL-63 AL-64 AL-65 AL-66 AL-67 AL-68 o AL-69 n AL-70 n AL-71 n 14 Enfermedad / Accidente 35.00/NADA 35.00/NADA 55.00/NADA 35.00/NADA 35.00/NADA 50.00/NADA 35.00/NADA 35.00/NADA 55.00/NADA 50.00 50.00/ 25.00 20.00 20.00 20.00 20.00 20.00 20.00 20.00 20.00 20.00 20.00 50.00 75.00/ 35.00 75.00/ 35.00 50.00/ 25.00 50.00/ 25.00 50.00/ 25.00 50.00/ 25.00 50.00 50.00/ 25.00 50.00/ 25.00 75.00/ 50.00 50.00 50.00/ 25.00 35.00/NADA 75.00/ 50.00 75.00/ 50.00 75.00/ 50.00 75.00/ 50.00 70.00 75.00/ 50.00 60.00 50.00 50.00 50.00/ 25.00 75.00/NADA CARACTERÍSTICAS @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA AL-72 n AL-73 AL-74 AL-75 AL-76 m AL-77 l AL-78 AL-79 AL-80 n AL-81 AL-82 AL-83 l AL-84 AL-85 l, AL-86 n AL-87 AL-88 AL-89 AL-90 AL-91 AL-92 AL-93 AL-94 AL-95 AL-96 AL-97 AL-98 AL-99 AK-01 n AK-02 AK-03 AK-04 n AK-05 AK-06 AK-07 AK-08 o AK-09 AK-10 n AK-11 n AK-12 n AK-13 v AK-14 n AK-15 z, AK-16 o AK-17 o AK-18 n Enfermedad / Accidente 75.00 35.00 75.00/ 50.00 75.00/ 50.00 75.00 50.00/NADA 75.00 75.00 40.00/NADA 20.00 75.00 50.00 20.00 75.00 20.00 30.00 50.00 75.00/ 50.00 50.00 75.00/ 50.00 150.00/NADA 75.00/ 50.00 75.00/ 35.00 75.00/ 35.00 50.00/ 25.00 50.00/ 25.00 50.00/ 25.00 30.00 50.00/NADA 50.00/NADA 50.00/NADA 75.00 75.00/NADA 75.00/NADA 75.00/NADA 45.00/NADA 50.00/NADA 75.00/ 75.00 75.00/ 75.00 75.00/ 25.00 75.00/ 50.00 10.00 100.00/ 100.00 50.00/ 30.00 50.00 30.00/NADA CARACTERÍSTICAS CUBIERTA @ @ * * @ @ * * @ @ @ @ @ @ @ * * * * * * * * * * * * * @ @ @ @ * * * @ * @ @ @ @ @ @ @ @ @ AK-19 o AK-20 n AK-21 n AK-22 n AK-23 n AK-24 n AK-25 n AK-26 n AK-27 n AK-28 n AK-29 n AK-30 n AK-31 n AK-32 o AK-33 n AK-34 n AK-35 n AK-36 n AK-37 n AK-38 o AK-39 o AK-40 n AK-41 AK-42 AK-43 AK-44 AK-45 z, AK-46 n AK-47 o AK-48 n AK-49 n AK-50 n AK-51 n AK-52 A AK-53 n AK-54 AK-55 AK-56 n AK-57 n, AK-58 n AK-59 n AK-60 n AK-61 AK-62 n AK-63 n AK-64 n 15 Enfermedad / Accidente 50.00 20.00 20.00 20.00 20.00 50.00 50.00/NADA 75.00/NADA 75.00/NADA 40.00/NADA 20.00/NADA 20.00 75.00 50.00 60.00/NADA 50.00/NADA 100.00/NADA 100.00/NADA 100.00/NADA 50.00 75.00 50.00/NADA 25.00 50.00/NADA 25.00 75.00 75.00 75.00 75.00/ 50.00 50.00/ 10.00 25.00 25.00 75.00 55.00/NADA 50.00 125.00/NADA 75.00 50.00.NADA 40.00/NADA 50.00 50.00/NADA 25.00/NADA * NADA 50.00 35.00/NADA CARACTERÍSTICAS @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ * * * * @ @ @ @ @ @ @ @ @ * * @ @ @ @ @ * @ @ @ 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA AK-65 AK-66 n AK-67 o AK-68 AK-69 AK-70 AK-71 AK-72 n AK-73 AK-74 AK-75 n AK-76 AK-77 AK-78 AK-79 AK-80 AK-81 AK-82 AK-83 AK-84 AK-85 AK-86 z AK-87 n AK-88 n AK-89 AK-90 AK-91 AK-92 AK-93 AK-94 n AK-95 n AK-96 AK-97 AK-98 AK-99 AM-01 AM-02 AM-03 AM-04 AM-05 o AM-06 AM-07 AM-08 AM-09 b AM-10 AM-11 Enfermedad / Accidente * 20.00 50.00 * * * * 30.00 * * 20.00 * 100.00 * * * * * * * 75.00 75.00 75.00 50.00 * * * * * 35.00/NADA 50.00 75.00 * * * 40.00/NADA 35.00/NADA 40.00 25.00 75.00/ 35.00 10.00 25.00/NADA 10.00 25.00 50.00 50.00/NADA CARACTERÍSTICAS CUBIERTA * @ @ * * * * @ * * @ * * * * * * * * * * @ @ @ * * * * * @ @ * * * * @ * * @ @ @ @ @ AM-12 c AM-13 AM-14 AM-15 AM-16 AM-17 n AM-18 n AM-19 n AM-20 n AM-21 AM-22 n AM-23 AM-24 o AM-25 AM-26 AM-27 B AM-28 c AM-29 o AM-30 n AM-31 o AM-32 n AM-33 n, AM-34 AM-35 n AM-36 n AM-37 AM-38 II AM-39 AM-40 o AM-41 z AM-42 AM-43 AM-44 n AM-45 AM-46 AM-47 AM-48 AM-49 AM-50 AM-51 AM-52 AM-53 AM-54 AM-55 AM-56 o AM-57 @ @ 16 Enfermedad / Accidente 50.00 25.00/NADA 50.00/NADA 50.00/ 25.00 75.00 50.00/NADA 50.00/NADA 50.00/NADA 50.00/NADA 25.00/NADA 100.00/NADA 25.00 40.00/ 5.00 50.00/NADA 50.00/NADA 75.00/NADA 30.00/NADA 50.00/NADA 25.00 50.00 20.00 30.00 25.00/NADA 75.00/NADA 50.00/NADA 20.00 50.00/NADA 50.00/NADA 35.00/NADA 75.00 50.00/ 25.00 50.00/NADA 25.00/ 10.00 20.00/NADA * * * 30.00/NADA 50.00 10.00/NADA 10.00/NADA 50.00 50.00 30.00 50.00 40.00/NADA CARACTERÍSTICAS * @ @ @ @ @ @ @ @ @ @ * * * * * @ @ @ * * @ * @ * * * * * * * * * * * * * * * @ @ * * * * * 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA AM-58 AM-59 AM-60 AM-61 AM-62 AM-63 AM-64 AM-65 AM-66 AM-67 AM-68 AM-69 AM-70 AM-71 AM-72 AM-73 AM-74 AM-75 AM-76 AM-77 AM-78 n AM-79 AM-80 AM-81 AM-82 AM-83 AM-84 AM-85 AM-86 AM-87 AM-88 AM-89 AM-90 AM-91 AM-92 AM-93 AM-94 n AM-95 AM-96 AM-97 AM-98 AM-99 AJ-01 l AJ-02 l AJ-03 l AJ-04 Enfermedad / Accidente 50.00 50.00 50.00 * 20.00/NADA 35.00/NADA 50.00 30.00 30.00 5.00/NADA * * * * 25.00/NADA 50.00/NADA 20.00 50.00/NADA 50.00 * 20.00 50.00/NADA 50.00 35.00 25.00 50.00 30.00/NADA 20.00 20.00 20.00 40.00/ 20.00 50.00/ 25.00 50.00/NADA 50.00/ NADA 50.00/ NADA 75.00/ 25.00 50.00/ 25.00 50.00/ 25.00 50.00 20.00 20.00 20.00 15.00/NADA 20.00/NADA 20.00/NADA NADA CARACTERÍSTICAS CUBIERTA * * * * @ @ * @ @ * * * * * @ @ @ @ @ * @ * @ @ * * @ @ @ @ n * @ @ @ @ * * * * * * @ @ @ * AJ-05 AJ-06 AJ-07 l AJ-08 n AJ-09 n AJ-10 n AJ-11 AJ-12 AJ-13 AJ-14 l AJ-15 l , AJ-16 l AJ-17 n AJ-18 n AJ-19 n AJ-20 AJ-21 AJ-22 AJ-23 n AJ-24 AJ-25 n AJ-26 AJ-27 n AJ-28 AJ-29 AJ-30 AJ-31 AJ-32 AJ-33 AJ-34 AJ-35 n AJ-36 AJ-37 AJ-38 AJ-39 AJ-40 AJ-41 AJ-42 AJ-43 AJ-44 AJ-45 AJ-46 AJ-47 n AJ-48 AJ-49 AJ-50 17 Enfermedad / Accidente NADA NADA 10.00/NADA 25.00 NADA 20.00/ 10.00 35.00/NADA 50.00 * 10.00/NADA 10.00/NADA 10.00/NADA 50.00/ 25.00 50.00/ 25.00 50.00/ 25.00 50.00 50.00 50.00 20.00/ 20.00 35.00 25.00/NADA 40.00/NADA 10.00/NADA 25.00 50.00 50.00 25.00 35.00 50.00/ 35.00 * 25.00/ 25.00 50.00 25.00/NADA 30.00 25.00/NADA 150.00/NADA 50.00/ 25.00 50.00/ 20.00 35.00 * 50.00/ 25.00 35.00 20.00/NADA 50.00/ 25.00 * 50.00/ 25.00 CARACTERÍSTICAS * * @ @ * * * * * @ @ @ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA AJ-51 AJ-52 AJ-53 AJ-54 AJ-55 AJ-56 AJ-57 AJ-58 AJ-59 AJ-60 AJ-61 AJ-62 n AJ-63 n AJ-64 AJ-65 AJ-66 AJ-67 AJ-68 AJ-69 AJ-70 AJ-71 AJ-72 AJ-73 AJ-74 AJ-75 AJ-76 n AJ-77 AJ-78 n AJ-79 AJ-80 AJ-81 AJ-82 AJ-83 AJ-84 AJ-85 AJ-86 AJ-87 n AJ-88 AJ-89 AJ-90 AJ-91 AJ-92 AJ-93 AJ-94 AJ-95 n AJ-96 n Enfermedad / Accidente 25.00 35.00 * 50.00 35.00/NADA 25.00/NADA 40.00 10.00 20.00/ 10.00 25.00 * 40.00/ 40.00 20.00/ 20.00 10.00 * * 40.00/NADA 50.00/NADA * 25.00/NADA 50.00/NADA 20.00 50.00/NADA * 35.00 50.00/NADA * 25.00/NADA * 50.00/NADA 35.00/NADA NADA 35.00 * NADA 10.00/NADA 35.00 10.00 10.00/NADA * 40.00 * 20.00 10.00/NADA 35.00/ 35.00 20.00 CARACTERÍSTICAS CUBIERTA @ @ * * * * * * * @ * * * * * * * * * * * * * * * * * * * * * @ * * * @ * @ * * * * * * * * AJ-97 AJ-98 AJ-99 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 18 Enfermedad / Accidente 20.00 30.00 20.00 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * CARACTERÍSTICAS * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 08-13-2015

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS CUBIERTA AN-01 AN-02 AN-03 AN-04 AN-05 AN-06 AN-07 AN-08 AN-09 AN-10 AN-11 AN-12 AN-13 o AN-14 o AN-15 o AN-16 AN-17 AN-18 AN-19 AN-20 o AN-21 AN-22 n AN-23 AN-24 AN-25 AN-26 ,n AN-27 AN-28 AN-29 AN-30 AN-31 III AN-32 n AN-33 n AN-34 n AN-35 C AN-36 C AN-37 D AN-38 AN-39 AN-40 E AN-41 n AN-42 D AN-43 AN-44 AN-45 AN-46 o AN-47 AN-48 AN-49 z AN-50 Enfermedad / Accidente 20.00 20.00 20.00 20.00 20.00 20.00 20.00 25.00 25.00 25.00 50.00/NADA 50.00/NADA 50.00 50.00 50.00 * * * * 50.00 * 50.00/ 25.00 * 50.00/ 25.00 * 50.00/NADA 20.00 35.00 50.00 50.00 40.00 75.00 40.00 20.00 45.00/NADA 45.00/NADA 25.00/NADA 30.00 70.00 50.00/ 25.00 25.00 50.00 50.00 * * 50.00 20.00/ 10.00 20.00/NADA 75.00 20.00/NADA CARACTERÍSTICAS CUBIERTA @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ * * * * * * @ * @ * @ @ @ @ @ @ @ @ @ @

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS 2 08-13-2015 CUBIERTA Enfermedad / Accidente CARACTERÍSTICAS CUBIERTA Enfermedad / Accidente CARACTERÍSTICAS AA-04 n 40.00/NADA @ AA-55 n 10.00 @ AA-05 n 25.00 @ AA-56 n 50.00/ NADA @ AA-06 n 50.00/NADA @ AA-57 x 15.00 @

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