|
Health Plan B 1M |
| |
Prefferred Provider
(In-Network Benefits)
|
Non-Prefferred Provider
(Out-of-Network Benefits) |
Policy Year Deductible
Does not apply toward Out-of-Pocket Maximum |
$1,100 per insured
$3,300 per family |
$3,000 per insured
$9,000 per family |
| Out-of-Pocket Maximum |
$3,300 per insured
$9,000 per family |
$9,000 per insured
$27,000 per family |
| Preauthorization Penalty |
Failure to preauthorize reduces benefits by 50% or $500, whichever is less. |
|
| Doctor Office Visits |
|
Office Visits |
$30 Non-Specialiast copay
$50 Specialist copay
|
50% after deductible
50% after deductible |
|
|
Hospital Services |
|
Inpatient Room & Board and other Inpatient charges |
80% after deductible |
50% after deductible |
|
Outpatient Room Surgery Facility |
80% after deductible |
50% after deductible |
|
| Emergency Care Services |
80% Deductible waived |
For more detailed information visit the plan documents:
|
|