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[Day]
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[Month]
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[Year]
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(
Hospitals List A
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(
Hospitals List B
)
Optional Out-Hospital plan
Out I - 85%
(X-Rays , Laboratory tests)
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(X-Rays , Laboratory tests)
Out II - 85%
(X-Rays , Laboratory tests , Medications , Dr. Visits)
Out II - 100%
(X-Rays , Laboratory tests , Medications , Dr. Visits)
None