CARTA #M0910427 SALA DE EMERGENCIApublicaciones.ssspr.com/Cartas/Documents/M0910427.pdf · Página...

CARTA CIRCULAR #M0910427 Página 1 de 2 9 de octubre de 2009

CARTA CIRCULAR #M0910427 9 de octubre de 2009 A LOS ADMINISTRADORES Y DIRECTORES MÉDICOS EN SALAS DE EMERGENCIA PARTICIPANTES DE TRIPLE-S SALUD

NUEVA VERSIÓN DE CUBIERTA AN-26, AN-28, AN-29, AN-3 0 Y AN-31

Triple-S Salud ofrece nuevas versiones de cubiertas de servicios ambulatorios identificada con los códigos AN-26, AN-28, AN-29, AN-30 y AN-31.

Versiones de Cubierta

Cubierta Base

Efectividad Características

AN-26 AL-09 Inmediata � $50.00 de copago por el uso de facilidades de sala de emergencia en caso de enfermedad.

� $10.00 de copago por el uso de facilidades de sala de emergencia si al llamar a Teleconsulta, recibe una recomendación de acudir a la sala de emergencia y como resultado recibe un número de registro que deberá proveer a la institución hospitalaria.

� Nada de copago por el uso de facilidades de sala de emergencia en caso de accidente.

AN-28 AL-09 Inmediata � $35.00 de copago por el uso de facilidades de sala de emergencia.

AN-29 AL-09 Inmediata � $50.00 de copago por el uso de facilidades de sala de emergencia.

AN-30 AG-90 Inmediata � $50.00 de copago por el uso de facilidades de sala de emergencia en caso de enfermedad o accidente.


CARTA CIRCULAR #M0910427 Página 2 de 2 9 de octubre de 2009

Versiones de Cubierta

Cubierta Base

Efectividad Características

AN-31 AH-96 Inmediata � $40.00 de copago por el uso de facilidades de sala de emergencia en caso de enfermedad o accidente.


Incluimos la página actualizada de la Tabla de Copagos correspondiente a los Servicios de Sala de Emergencia.

Si necesita información adicional, comuníquese con nuestro Departamento de Relaciones Profesionales al 787-749-4700 ó al 1-877-357-9777 (libre de cargos para llamadas de larga distancia).

Cordialmente, Francisco Joglar Pesquera, MD, FACP Ana D. Oyola, MHSA Vicepresidente Senior Directora División de Asuntos Médicos, Departamento de Hospitales y Dentales y Profesionales Servicios Institucionales im Anejo

SALA DE EMERGENCIA CÓDIGOS DE CUBIERTA/COPAGOS

Departamento de Comunicación Técnica División de Mercadeo y Desarrollo de Productos 1 cc 10/09/09

CUBIERTA COPAGO CARACTERÍSTICAS CUBIERTA COPAGO CARACTERÍSTICAS

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




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




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




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




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




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




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




AG-01 m $50.00/$25.00 @ AG-47 n $20.00 @ AG-02 m $50.00/$25.00 @ AG-48 n $20.00 @ AG-03 m $50.00/$25.00 @ AG-49 l, n $50.00/NADA @ AG-04 n $30.00 @ AG-50 l, n $20.00/NADA @ AG-05 m $50.00/$25.00 @ AG-51 n $50.00 @ AG-06 l, n $75.00/$50.00 @ AG-52 l, n $50.00/NADA @ AG-07 n $40.00 @ AG-53 m $50.00/$25.00 @ AG-08 n $30.00 @ AG-54 l, n $30.00/NADA @ AG-09 n $30.00 @ AG-55 n $40.00 @ AG-10 l, n $50.00/NADA @ AG-56 l, n $20.00/NADA @ AG-11 n $35.00 @ AG-57 n $50.00 @ AG-12 l, n $50.00/NADA @ AG-58 l, n $15.00/NADA @ AG-13 l, o $125.00/25.00 @ AG-59 n $20.00 @ AG-14 n $100.00 @ AG-60 n $20.00 @ AG-15 l, n $50.00/NADA @ AG-61 * * AG-16 m $50.00/$25.00 @ AG-62 l, n $50.00/NADA @ AG-17 n $35.00 @ AG-63 n $20.00 @ AG-18 n $50.00 @ AG-64 * * AG-19 l, n $35.00/NADA @ AG-65 o $50.00 * AG-20 l, n $30.00/NADA @ AG-66 * * AG-21 l, n $35.00/NADA @ AG-67 o $50.00/NADA @ AG-22 m $50.00/$25.00 @ AG-68 B $50.00/$25.00 * AG-23 n $25.00 @ AG-69 l, n $50.00/$20.00 @ AG-24 m $50.00/$25.00 @ AG-70 * * AG-25 n $20.00 @ AG-71 l, n $50.00/$25.00 @ AG-26 n $20.00 @ AG-72 l, n $50.00/$25.00 @ AG-27 n $20.00 @ AG-73 n $20.00 @ AG-28 n $30.00 @ AG-74 n $50.00 @ AG-29 l, n $5.00/NADA @ AG-75 $50.00 @ AG-30 n $20.00 @ AG-76 n $50.00 @ AG-31 l, n $50.00/NADA @ AG-77 n $50.00 @ AG-32 l, n $50.00/NADA @ AG-78 l, n $20.00/NADA @ AG-33 n $35.00 @ AG-79 n $35.00 @ AG-34 n $35.00 @ AG-80 n $50.00 @ AG-35 n $50.00 @ AG-81 n $20.00 @ AG-36 l, n $50.00/NADA @ AG-82 l, n $35.00/NADA @ AG-37 o $50.00 @ AG-83 n $50.00 @ AG-38 l, n $25.00/NADA @ AG-84 n $35.00 @ AG-39 n $50.00 @ AG-85 n $50.00 @ AG-40 n $50.00 @ AG-86 l, n $20.00/NADA @ AG-41 n $20.00 @ AG-87 o $50.00 @ AG-42 l, o $50.00/$25.00 @ AG-88 o $50.00 @ AG-43 m $50.00/$25.00 @ AG-89 o $50.00 @ AG-44 l, n $50.00/NADA @ AG-90 n $20.00 @ AG-45 l, n $35.00/NADA @ AG-91 o $50.00 @ AG-46 m $50.00/$25.00 @ AG-92 n $30.00 @




AG-93 n $50.00 @ AH-40 n $50.00 @ AG-94 o $50.00 @ AH-41 n $50.00 @ AG-95 n $50.00 @ AH-42 l, n $50.00/NADA @ AG-96 l, n $50.00/NADA @ AH-43 * * AG-97 n $20.00 @ AH-44 n $50.00/NADA @ AG-98 * * AH-45 l, q $75.00/NADA @ AG-99 l,n $20.00/NADA @ AH-46 o $50.00 @ AH-01 l, n $50.00/NADA @ AH-47 o $50.00/NADA @ AH-02 n $50.00 @ AH-48 n $35.00/NADA @ AH-03 l, n $40.00/NADA @ AH-49 n $40.00/NADA @ AH-04 l, n $50.00/$25.00 @ AH-50 n $40.00/NADA @ AH-05 n $20.00 @ AH-51 n $40.00/NADA @ AH-06 n $50.00/NADA @ AH-52 o $35.00/NADA @ AH-07 n $50.00/NADA @ AH-53 * * AH-08 y $125.00 @ AH-54 n $25.00 @ AH-09 l, n $50.00/NADA @ AH-55 n $50.00/NADA * AH-10 n $20.00 @ AH-56 $5.00 @ AH-11 n $40.00 @ AH-57 * * AH-12 * * AH-58 n $50.00/NADA @ AH-13 l, n $50.00/NADA @ AH-59 n $20.00 @ AH-14 n $50.00 @ AH-60 n $50.00 @ AH-15 n $20.00/NADA @ AH-61 l, n $30.00/NADA @ AH-16 lll $50.00 @ AH-62 n $20.00 @ AH-17 n $50.00 @ AH-63 n $20.00 @ AH-18 n $10.00 @ AH-64 l, n $50.00/NADA @ AH-19 n $10.00/NADA @ AH-65 l, n $30.00/NADA @ AH-20 n $50.00 @ AH-66 n $50.00 @ AH-21 n $30.00 @ AH-67 l, n $50.00/NADA @ AH-22 n $30.00/NADA @ AH-68 n $50.00 @ AH-23 n $50.00 @ AH-69 n $20.00 @ AH-24 o $75.00 @ AH-70 n $50.00 @ AH-25 n $50.00/$10.00 @ AH-71 n $35.00 @ AH-26 o $75.00 @ AH-72 n $50.00 @ AH-27 o $50.00 @ AH-73 ll $50.00/NADA @ AH-28 o $50.00 @ AH-74 l, n $25.00/NADA @ AH-29 n $20.00 @ AH-75 l, n $50.00/NADA @ AH-30 n $10.00 @ AH-76 n $20.00 @ AH-31 o $100.00/50.00 @ AH-77 l, n $25.00/NADA @ AH-32 n $75.00/NADA @ AH-78 l, n $30.00/NADA @ AH-33 n $50.00 @ AH-79 n $50.00 @ AH-34 o $50.00 @ AH-80 n $40.00 @ AH-35 n $75.00 @ AH-81 n $50.00 @ AH-36 o $100.00/50.00 @ AH-82 n $50.00 @ AH-37 n $30.00 @ AH-83 * * AH-38 n $75.00 @ AH-84 l, n $35.00/NADA @ AH-39 o $50.00/$20.00 @ AH-85 * *




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




AI-79 * * AL-26 n $35.00/NADA @ AI-80 * * AL-27 n $35.00/NADA @ AI-81 * * AL-28 n $55.00/NADA @ AI-82 * * AL-29 n $35.00/NADA @ AI-83 * * AL-30 n $35.00/NADA @ AI-84 * * AL-31 n $50.00/NADA @ AI-85 * * AL-32 n $35.00/NADA @ AI-86 * * AL-33 n $35.00/NADA @ AI-87 n $25.00 @ AL-34 n $55.00/NADA @ AI-88 n $50.00 @ AL-35 n $50.00 @ AI-89 n $20.00 @ AL-36 $50.00/NADA @ AI-90 NADA @ AL-37 o $50.00 @ AI-91 n $50.00/NADA @ AL-38 $25.00/NADA @ AI-92 n $25.00/NADA @ AL-39 $10.00 @ AI-93 n $30.00 @ AL-40 $10.00/NADA @ AI-94 n $20.00 @ AL-41 o $50.00 @ AI-95 * * AL-42 $20.00 @ AI-96 n $75.00/NADA @ AL-43 $20.00 @ AI-97 n $20.00 @ AL-44 $20.00 @ AI-98 n $20.00 @ AL-45 $30.00 @ AI-99 n $20.00 @ AL-46 o $50.00 @ AL-01 n $40.00 @ AL-47 $50.00 @ AL-02 l, o $75.00 @ AL-48 $30.00/NADA @ AL-03 l, o $50.00 @ AL-49 $20.00/NADA @ AL-04 l, o $50.00 @ AL-50 $25.00 @ AL-05 * * AL-51 $50.00 @ AL-06 $20.00 @ AL-52 $50.00 @ AL-07 $50.00 @ AL-53 $50.00 @ AL-08 $50.00/$25.00 @ AL-54 o $50.00 @ AL-09 $20.00 @ AL-55 $35.00 @ AL-10 $40.00/NADA @ AL-56 $50.00 @ AL-11 b $75.00/$25.00 @ AL-57 o $50.00/NADA @ AL-12 $20.00 @ AL-58 o $50.00 @ AL-13 $50.00 @ AL-59 $50.00/NADA @ AL-14 l $50.00/NADA @ AL-60 $35.00/NADA @ AL-15 l $100.00/$50.00 @ AL-61 $50.00 @ AL-16 l $75.00/$25.00 @ AL-62 $50.00/NADA @ AL-17 l $50.00/NADA @ AL-63 $50.00 @ AL-18 o $50.00/$25.00 @ AL-64 o $50.00 @ AL-19 c $50.00/$10.00 @ AL-65 $40.00 @ AL-20 n $50.00/NADA @ AL-66 $20.00 @ AL-21 n $50.00/NADA @ AL-67 $40.00 @ AL-22 n $50.00/NADA @ AL-68 o $50.00 @ AL-23 n $30.00 @ AL-69 n $50.00 @ AL-24 z $75.00 @ AL-70 n $50.00/$25.00 @ AL-25 B AL-71 n $75.00/NADA @




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




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




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




AJ-51 $25.00 * AJ-97 $20.00 * AJ-52 $35.00 * AJ-98 $30.00 * AJ-53 n $40.00/$40.00 * AJ-99 $20.00 * AJ-54 $50.00 * * * * AJ-55 $35.00/NADA * * * * AJ-56 * * * * * AJ-57 $25.00 * * * * AJ-58 $10.00 * * * * AJ-59 $20.00/$10.00 * * * * AJ-60 $25.00 * * * * AJ-61 $25.00 * * * * AJ-62 n $40.00/$40.00 * * * * AJ-63 n $20.00/$20.00 * * * * AJ-64 $10.00 * * * * AJ-65 n $50.00/$50.00 * * * * AJ-66 * * * * * AJ-67 $40.00 * * * * AJ-68 $50.00/NADA * * * * AJ-69 $25.00 * * * * AJ-70 $25.00 * * * * AJ-71 $50.00/NADA * * * * AJ-72 $0 * * * * AJ-73 $50.00 * * * * AJ-74 n $50.00/NADA * * * * AJ-75 $35.00 * * * * AJ-76 n $50.00/NADA * * * * AJ-77 $50.00/NADA * * * * AJ-78 n $25.00/NADA * * * * AJ-79 $25.00 * * * * AJ-80 $50.00 * * * * AJ-81 $50.00 * * * * AJ-82 NADA * * * * AJ-83 $50.00 * * * * AJ-84 $25.00/NADA * * * * AJ-85 $20.00 * * * * AJ-86 $25.00 @ * * * AJ-87 n $10.00/NADA * * * * AJ-88 $10.00/NADA * * * * AJ-89 $10.00/NADA * * * * AJ-90 $40.00 * * * * AJ-91 $40.00 * * * * AJ-92 $20.00 * * * * AJ-93 $20.00 * * * * AJ-94 $10.00/NADA * * * * AJ-95 n $35.00/$35.00 * * * * AJ-96 n $20.00/NADA * * * *




AP-01 * * AP-47 * * AP-02 $50.00 * AP-48 * * AP-03 $20.00 * AP-49 * * AP-04 n $30.00/$30.00 * AP-50 * * AP-05 n $25.00/NADA * AP-51 * * AP-06 n $50.00/$50.00 * AP-52 * * AP-07 n $50.00/NADA * AP-53 * * AP-08 n $40.00/$40.00 * AP-54 * * AP-09 $40.00 * AP-55 * * AP-10 *5.00/NADA * AP-56 * * AP-11 $50.00 * AP-57 * * AP-12 * * AP-58 * * AP-13 $50.00/$50.00 * AP-59 * * AP-14 n $50.00/$25.00 * AP-60 * * AP-15 n $50.00/$25.00 * AN-06 $20.00 * AP-16 n $50.00/$25.00 * AN-07 $20.00 * AP-17 n $50.00/$25.00 * AN-13 $50.00/$25.00 * AP-18 v N/C * AN-14 $50.00/$25.00 * AP-19 $40.00/$40.00 * AN-15 $50.00/$25.00 * AP-20 $50.00/NADA * * * * AP-21 $50.00/$50.00 * * * * AP-22 $50.00/$50.00 * * * * AP-23 $50.00 * * * * AP-24 $50.00 * * * * AP-25 $35.00 * * * * AP-26 $20.00 * * * * AP-27 $20.00/NADA * * * * AP-28 $25.00/NADA * * * * AP-29 $35.00/NADA * * * * AP-30 $50.00/$25.00 * * * * AP-31 20% * * * * AP-32 $25.00/$25.00 * * * * AP-33 $40.00 * * * * AP-34 * * * * * AP-35 * * * * * AP-36 * * * * * AP-37 * * * * * AP-38 * * * * * AP-39 * * * * * AP-40 * * * * * AP-41 * * * * * AP-42 * * * * * AP-43 * * * * * AP-44 * * * * * AP-45 * * * * * AP-46 * * * * *




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 * * * * * AN-14 * * * * * AN-15 * * * * * AN-16 * * * * * AN-17 * * * * * AN-18 * * * * * AN-19 * * * * * AN-20 * * * * * AN-21 * * * * * AN-22 * * * * * AN-23 * * * * * AN-24 * * * * * AN-25 * * * * * AN-26 + $50.00/NADA * * * * AN-27 $20.00 * * * * AN-28 $35.00 * * * * AN-29 $50.00 * * * * AN-30 * * * * * AN-31 III $40.00 * * * * AN-32 n $75.00 * * * * AN-33 $40.00/ NADA * * * * AN-34 $20.00/NADA * * * * AN-35 * * * * * AN-36 * * * * * AN-27 * * * * * AN-38 * * * * * AN-39 * * * * * AN-40 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *



NOTAS: Los copagos aplican exclusivamente al uso de la facilidad y a los servicios contratados con ella. Consultas que no envuelvan una condición médica aguda, o que no sean resultado de un accidente, serán pagadas en su totalidad por el asegurado y no son reembolsables por Triple-S. Los límites establecidos para estos servicios no aplican en las facilidades que han contratado el servicio con Triple-S mediante una tarifa global. * Cubierta sin asignar. @ Cubre medicamentos y materiales adicionales a los incluidos en la bandeja de sutura por condiciones de

accidente o enfermedad. (a) Aplica periodo de espera. (b) Aplica al Programa Medicare Advantage (c) $20.00 de copago si el asegurado recibe recomendación de Teleconsulta. (l) El copago corresponde a emergencias agudas y el segundo a emergencias por accidente. (m) Si se recibe recomendación de Teleconsulta para la visita a Sala de Emergencia se cobrará el copago

menor. (n) Este copago no aplicará si el asegurado al llamar a Teleconsulta recibe una recomendación de acudir a la

sala de emergencia y como resultado recibe un número de registro que deberá proveer a la institución hospitalaria.

(o) Si se recibe recomendación de Teleconsulta para la visita a Sala de Emergencia se cobrará $25.00 de

copago. (q) Si se recibe recomendación de Teleconsulta para la visita a Sala de Emergencia se cobrará $40.00 de

copago. (r) Cubre medicamentos y materiales en casos de enfermedad que no son resultado de accidente, hasta un

máximo de $50.00; y hasta un máximo de $100.00 por condiciones de accidente. (s) Cubre medicamentos y materiales sin límite para condiciones de accidente. No los cubre casos de

enfermedad. (t) Cubre medicamentos y materiales sin límite por condiciones de accidente. En casos de enfermedad, hasta

un máximo de $100.00. (u) Cubre medicamentos y materiales adicionales a los incluidos en la bandeja de sutura por condiciones de

trauma o accidente. Cubre medicamentos y materiales en casos de enfermedad que no son resultado de un accidente hasta un máximo de $75.00. Máximo incluye servicio médico.

(v) No aplica el Programa de Teleconsulta. (x) El asegurado siempre pagará el deducible, independientemente de si recibe una recomendación de

Teleconsulta para visitar una sala de emergencia. (y) Si se recibe recomendación de Teleconsulta para la visita a Sala de Emergencia se cobrará $75.00 de

copago.



NOTAS: (z) Si se recibe recomendación de Teleconsulta para la visita a Sala de Emergencia se cobrará $50.00 de

copago. (ll) Si se recibe recomendación de Teleconsulta para la visita a Sala de Emergencia se cobrará $35.00 de

copago.

(lll) Si se recibe recomendación de Teleconsulta para la visita a Sala de Emergencia se cobrará $20.00 de copago.

+ Si se recibe recomendación de Teleconsulta para la visita a Sala de Emergencia se cobrará $10.00 de

copago. A Si se recibe recomendación de Teleconsulta para la visita a Sala de Emergencia se cobrará $30.00 de

copago. B Este copago no aplicará si se recibe recomendación de Teleconsulta para la visita a Sala de Emergencia.

CARTA #M0910427 SALA DE EMERGENCIApublicaciones.ssspr.com/Cartas/Documents/M0910427.pdf · Página...

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