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(C <br /> g5.- Gui crexgistute. le(ox- <br /> Personal Care Plan <br /> of North Carolina Inc. <br /> Summary of Benefits <br /> Services Benefits <br /> Physician Services <br /> Office visits (including family planning, <br /> well-baby care and routine office visits) <br /> - During normal office hours $10 copayment <br /> - After normal office hours $15 copayment <br /> 1 Home visits $10 copayment <br /> Referral consultation with specialists Pays 100% <br /> Surgical and obstetrical services Pays 100% <br /> Laboratory procedures and X-ray examinations Pays 100% <br /> Inpatient care Pays 100% <br /> Short-term rehabilitation services (60 day period) Pays 100% <br /> Mental Health Services <br /> Outpatient care (up to 20 visits per calendar year) Pays 50% <br /> Inpatient care (up to 30 days per calendar year) Pays 80% <br /> Care for Alcohol and Drug Abuse Conditions <br /> $12,000 lifetime maximum for inpatient and <br /> outpatient care, with unlimited detoxification days <br /> Medical care (up to 20 visits per calendar year) Pays 100% <br /> 1 Detoxification (no limit on number of days) Pays 100% <br /> Inpatient care (up to 30 days per calendar year) Pays 100% <br /> Inpatient Hospital Services <br /> General surgical and medical care Pays 100% <br /> Intensive and cardiac care Pays 100% <br /> Semiprivate room and board Pays 100% <br /> Skilled nursing facility care (100 days per calendar year) Pays 100% <br /> Outpatient Hospital Services <br /> 1 X-ray, laboratory and diagnostic tests Pays 100°%° <br /> 1 Surgery Pays 100% <br /> Emergency care $25 copayment (waived if <br /> hospitalized) • <br /> Other Services <br /> Ambulance services Pays 100% <br /> Private duty nursing Pays 100% <br /> Durable medical equipment Pays 100% <br /> Home Health Agency services Pays 100% <br /> Blood and blood plasma Pays 100% <br /> 1 Prescription Drugs $6 copayment per prescription or <br /> refill, includes oral contraceptives, <br /> diaphragms <br /> This is a summary and is not the insurance contract, and only the actual certificate provisions <br /> will apply. You may request a copy of the certificate or handbook from your group <br /> administrator. <br /> For more information about the Personal Care Plan, call 1-800-222-9718. <br /> Your policy is renewable at the option of the insurer. <br />