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. . �; <br /> APPENDIX B <br /> HEALTH INSURANCE POLICY MINIMUM STANDARDS <br /> Minimum Benefits. In the instance the Partner Organization chooses to provide <br /> healthcare insurance coverage to the Member, the coverage proyided must include the <br /> following minimum benefits: <br /> �.a:� . Physician services for illness or injury . , .� . ;` ,, �:. ;•�, <br /> b. Hospital room and board <br /> c. Emergency room <br /> d. X-ray and, laboratory , <br /> e. Prescription drugs , � <br /> f. Limited mental/nervous disorders <br /> g. Limited substance abuse coverage <br /> h. An annual deductible of no more than $250 charges per member <br /> i. No more than $1,000 total annual out-of-pocket per member <br /> j. A 20% co-pay or a comparable fixed fee with the exception of a 50% co-pay <br /> for mental and substance abuse care <br /> k. A maximum benefit of at least $50,000 per occurrence or cause <br /> ' <br /> �:. `�` <br /> Public Allies Partner Organization Agreement 2011-2012 • 4 <br />