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<br />Outpatiept Hospital Services <br />- Diagnjostic tests, preadmission test~ 100% <br /> and d:ams, lab, and x-ray <br />- Che~otherapy and radiation Subject to deductible and 80% coinsurance, 100% thereafter. <br /> thera!?y; physical, occupational, <br /> and sjJeech 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 Subject to deductible and 80% coinsurance, 100% thereafter. <br />_ Eme~gency Room <br />- Physician Services <br />Ambulance <br />Medical1y necessary transport to Subject to deductible and 80% coinsurance, 100% thereafter. <br />nearest ftlcility <br />Mental )Iealth and Chemical <br />Dependency Care <br />- Inpatient Care Subject to deductible and 80% coinsurance, 100% thereafter. <br />- Outpatient Care <br />- Prot~ssional Care <br />Dependent 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 lA) <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 $10.00 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 ditTerence. 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 />11103/04 <br /> <br />2 <br />