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Physician Services

80%

60%

80%

75%

Hospital –In-patient

80%

60%

80%

75%

Hospital –Out-patient

80%

60%

80%

75%

Emergency Room

80%

60%

80%

75%

X-Rays, Laboratory

80%

60%

80%

75%

Adult Wellness/Preventive

100%

Not Covered

100%

Not Covered

Services

Maternity – Attending

100%

90%

100%

90%

Calendar Year Deductible

$1,050

$1,050

– Individual Coverage

Calendar Year Deductible

$2,100

$2,100

Maternity – Hospital; Other Services

80%

60%

80%

75%

Well-Child Care (Birth to 2 Years of Age) Ambulatory Surgical Facility

100%

Not Covered

100%

Not Covered

80%

60%

80%

75%

Cardiac Rehabilitation (outpatient)

80%

60%

80%

75%

Chiropractic Services

80% 80%

60% 60%

80% 80%

75% 75%

Durable Medical Equipment

Home Infusion Therapy

80%

60%

80%

75%

Nurse Practitioner Occupational Therapy

80% 80%

60% 60%

80% 80%

75% 75%

Optometric Services Organ Transplants Physical Therapy

80% 80% 80% 80%

60% 60% 60% 60%

80% 80% 80% 80%

75% 75% 75% 75%

Private Duty and Home Health Nursing Services

Speech Therapy

80%

60%

80%

75%

Physician

$4,900

$7,900

in the Covered

Services section.

100%

Not Covered

100%

Not Covered

100%

Not Covered

100%

Not Covered

100%

Not Covered

100%

Not Covered

All benefits are subject

to the deductible unless otherwise noted

$7,900

Summary of Base Coverage Medical Benefits

$3,950

Well-Newborn Nursery Care

Well-Child Physician Office Visits

Specified Routine Tests

High Option for Children

Coinsurance Maximum – Family Coverage

$4,900

This is only a summary of the medical benefits under the Base Coverage. It does not provide all details and provisions of the Plan. Some limitations and exclusions apply and can be found within the Plan Document.

$2,450

Lifetime Maximum Benefits

In-Area Participants

Out-of-Area Participants

$ 3 , 9 5 0

In-Network

  • Family Coverage

Coinsurance Maximum – Individual Coverage

$ 2 , 4 5 0

Out-of-Network In-Network $1,000,000

Out-of-Network

14

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