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25 <br /> 10/0 PLAN <br /> IV. PRIVATE DUTY NURSING <br /> Must be prior approved by the Medical Director. <br /> A. In Hospital $50/day Copayment, <br /> $500 maximum Copayment per <br /> Contract year per person. <br /> B. At Home Full Coverage <br /> V. EMERGENCY SERVICES <br /> A. Emergency Services $35 Copayment <br /> • <br /> in and out of the per visit <br /> Service Area <br /> Plan must be notified within 48 hours <br /> of an Emergency hospital admission. <br /> B. Professional Full Coverage <br /> Ambulance Service <br /> VI. MENTAL HEALTH CARE AND <br /> CHEMICAL DEPENDENCY TREATMENT <br /> Limited to Crisis Intervention and Evaluation for Mental <br /> Health Care and Medically Necessary Care and Treatment of <br /> Chemical Dependency. Chemical Dependency Treatment benefits <br /> offset Mental Health benefits. Maximum chemical dependency <br /> benefit per member per twenty-four (24) month period not to <br /> exceed six thousand ($6,000) dollars and three thousand <br /> ($3,000) dollars in any twelve (12) month period. Maximum <br /> lifetime chemical dependency benefit per member not to exceed <br /> twelve thousand ($12,000) dollars. <br /> Outpatient <br /> A. Maximum of 20 $20 Copayment <br /> visits per per visit <br /> Contract Year <br /> Inpatient <br /> B. Maximum of thirty $100/day <br /> (30) days per Copayment, <br /> Contract Year $1,000 per <br /> Contract Year <br /> maximum Copayment <br /> per person <br /> 21 <br />