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SCHEDULE OF BENEFITS <br /> <br /> for <br /> <br /> CHEKICAL DEPENDENCY TREAI~IT BENEFITS <br /> <br /> Subject to the Exclusions, General Provisions, conditions, and limitations of <br /> chis Contract, a Hember is entitled to the benefits for Covered Services <br /> described in the Chemical Dependency Treatment Benefits Description section <br /> during a Benefit Period as specified in this Schedule of Benefits. <br /> <br /> SERVICES BENEFIT OPTIONS <br /> <br /> BENEFIT PERIOD A calendar year in which S,000 dollars <br /> in benefits are provided. <br /> <br /> F~XIHUHBENEFITS A lifetime maximum of ~16,000. <br /> COVERED SERVICES <br /> <br /> INPATIENT/RESIDENTIAL 80% of Provider~s Reasonable Charge. <br /> FACILITY SERVICES <br /> <br /> PROFESSIONAL SERVICES 80% of Provider's Reasonable Charge. <br /> <br />H126B-CD-1 <br /> <br /> <br />