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The initial $ 4,900 of coinsurance and co-payments is applied to both the in and out-of-network coinsurance/co-payment maximum. After the initial $4,900 has been applied, only the coinsurance amount for services rendered by non-participating providers will be applied to the additional $3,000 out-of-network coinsurance/co-payment maximum. Once the annual coinsurance/co-payment maximum is met, the Plan pays 100% of the allowable charge for covered medical expenses and prescription drugs for the remainder of that calendar year, except as otherwise specified.

The Plan will never pay 100% for those expenses that do not apply toward satisfying the coinsurance/co-payment maximum.

Coinsurance Once a participant has met the calendar year deductible, the Plan pays a portion of the allowable charge for covered medical expense. The participant pays the remainder in the form of coinsurance.

Any fees charged by a non-participating provider that are above the allowable charge are not part of the coinsurance amount. The Plan will not pay any portion of these charges.

Helpful Tip: Participating providers agree not to charge any amount above the Plan’s allowable charge.

Do These Expenses Count Towards The Coinsurance/Co-Payment Maximum?


  • The coinsurance paid for hospital inpatient services

  • The coinsurance paid for other covered expenses

  • Coinsurance and other expenses for treatment of substance abuse (alcohol and/or drug) and mental health conditions

  • The private room co-payment

  • The emergency room co-payment

  • Prescription drug co-payments


  • The calendar year deductible

  • Expenses in excess of the allowable charge

  • Expenses in excess of Plan maximum limits

  • Utilization review penalties

  • Services not covered by the Plan including all those found in the Medical Limitations and Exclusions section

  • Generic drug differential amounts

  • Services not considered medically necessary


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