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HH ''s How Major Medical Work:"-~~: GSP MN.._ before you become eligible for Medicare Part A because of your age WHAT PRU Pays and What YOU Pay In-Hospital Benefits PRU pays 100% THEN THEN PRU pays 100% • Room, board up to hospital maximum • _PRU pays 80% for the restofthe • Services, supplies ~ selected*** ~ calendar year YOU pay~0 YOU pay 20% YOU PaY 0 until you've paid $500* Other Benefits-In ~ ~ THEN ~ " ~ THENPRU pays 100% and Out of Hospital ,PRU pays 80% for the rest of~the • • Doctor visits** calendar year i • Surgery u u ,: ~ • Services, supplies YOU pay. the $100 deductible YOU pay 20% . 9 YOU pay 0 until you've paid $500* irst-Dollar Options PRU. a~ s 100 /o _ • # P Y °_ THEN ~ ~ ~ ~ ~ ~ •• _ THEN . d 4 THEN. PR.U pays 1..00% { • Surgery • up to maximum for ~ *** YOU pay PRU pays 80% • for the rest of the • Supplemental Accident each option _ the$100 calerdar year . deductible ~ • Diagnostic X-ray & Lab YOU a 0 p Y ~ YOU pay 20% YOU pay 0 j • In-Hospital Doctor Calls .. - - until you've paid $500* ~ ~ ~ 1 • Maternity ~ PRU pays 100% up.to maximum*** tDoesn't apply to Dental Expense Insurance Note: Details of these benefits are on following pages. *Afteryour payments (not counting deductibles) forall covered expenses in the calendaryear and priorthree months add up to $500, -Prudential will pay 100% of further eligible expenses for the rest ofthe calendaryear. This $500 limit also applies'to each other covered person in the family who has satisfied the required deductible: A family's co-payments, after no more than two deductibles, are limited to a total of $1,000 in a 15-month period. After that, Prudential will pay 100% of eligible expenses during the rest of the current year for all covered family members. **Certain doctor visits for mental and nervous conditions are subject to specified limits for eligible charges and yearly maximum benefit, and to 50%'-rather than 80% payment allowance. The maximum for these doctor visits and all other related expenses for care and treatment of those conditions is $20,000 for each person. Up to $1,000 of the amount used is restored at the beginning of each calendar year the plan is in force. ***As stated in booklet.