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<br />Outpatiept Hospital Services <br />- Diagnostic tests, preadmission test 100% <br /> and exams, lab, and x-ray <br />- Chemotherapy and radiation Subject to deductible and 80% coinsurance, 100% thereafter. <br /> therapy; physical, occupational, <br /> and speech therapy; kidney <br /> dialy$is, scheduled outpatient <br /> surgery <br />- Nonemergency, illness related Subject to deductible and 80% coinsurance, 100% thereafter. <br /> visits <br />Emerge$cy Care <br />- Emergency Room 100% after $75 copay <br />- Physician Services <br />Ambulance <br />MedicaUy necessary transport to Subject to deductible and 80% coinsurance, 100% thereafter. <br />nearest facilitv <br />Mental Health and Chemical <br />Dependency Care <br />- Inpatient Care Subject to deductible and 80% coinsurance, 100% thereafter. <br />- Outpatient Care <br />- Professional Care 100% after $15 office visit copay. <br />Dependient Child Age Limit To age 19, full time student to age 25; through the calendar <br /> . month of the birthday. <br />Prescription Drugs (Gold Net Plan IA) <br />31 Day limit 100% after member payment of a $10.00 copay or 20% coinsurance, <br /> whichever is greater, for generic drugs included on the formulary list <br /> up to the prescription drug out-of-pocket maximum. 100% after <br /> member payment of a $\0.00 copay or 20% coinsurance, whichever is <br /> greater, for name brand drugs included on the formulary list and for <br /> which there is no generic available up to the prescription drug out-of- <br /> pocket maximum. If generic is available and the name brand drug is <br /> selected, the patient pays the difference. No coverage for drugs not on <br /> the formulary list. Maximum copay is $30.00. <br />Medical Supplies Subject to deductible and 80% coinsurance, 100% thereafter. <br />Lifetime Maximum Per Person $3 million <br /> <br />If there is a discrepancy between this Summary and the Contract, the Contract is considered correct. <br /> <br />11/03/04 <br /> <br />2 <br />