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CABARRUS COUNZY EMPLOYEES Summary of Benefits PLAN 3 Inpatient Hospital Benefits Semi-Private Room - 70 Days ............................... Paid In Full Intensive Care Unit - 70 Days'. ............................ Paid In Full Ancillaries - 70 Days~ .................................... Paid In Full Deductible (per admission) ................................ $100.00 Outpatient Benefits Accidents - 72 Hours .................................. Paid In Full Outpatient Surgery (Hospital Charges) ..................... Paid In Full Surgical Benefits $1,000 Maximum - Based on sbrgical schedule determined by complexity of procedure, Benefits are paid for services received in or out of the hospital Inpatient Medical Benefits $15.00 1st Day $]0.00 2nd Day $ 5.00 3rd and subsequent benefit days Supplemental Benefits - Major Medical Lifetime Maximum ............................................ $250,000 Calendar Year Deductible Per Participant ........................ $100 Maximum Number of Deductibles Per Family ......................... Two Benefit Payments 50% of UCR charges for outpatient psychiatric care and 80% of UCR charges for all othe~ covered services up to $3,000 per participant (but not over ~7,500 per family). 100% UCR charges above $3,000 per participant ($7,500 per family).