BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Outpatient Professional Services
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible
Surgeon Radiologist Pathologist Anesthesiologist Urgent Care Services
Physician’s Office Visit
80% after plan deductible
80% of the Maximum Reimbursable Charge after plan deductible 80% of the Maximum Reimbursable Charge after plan deductible 80% of the Maximum Reimbursable Charge after plan deductible 80% of the Maximum Reimbursable Charge after plan deductible
Urgent Care Facility or Outpatient Facility Outpatient Professional Services (radiology, pathology, physician) X-ray and/or Lab performed at the Urgent Care Facility (billed by the facility as part of the UC visit) Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans, PET Scans etc.)
80% after plan deductible
80% after plan deductible
80% after plan deductible
80% after plan deductible
80% of the Maximum Reimbursable Charge after plan deductible
Emergency Services
Physician’s Office Visit Hospital Emergency Room
80% after plan deductible 80% after plan deductible 80% after plan deductible
80% after plan deductible 80% after plan deductible 80% after plan deductible
Outpatient Professional Services (radiology, pathology, ER physician) X-ray and/or Lab performed at the Emergency Room Facility (billed by the facility as part of the ER visit) Independent X-ray and/or Lab Facility in conjunction with an ER visit Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans, PET Scans etc.)
80% after plan deductible
80% after plan deductible
80% after plan deductible
80% after plan deductible
80% after plan deductible
80% after plan deductible
Air Ambulance
80% after plan deductible
80% after plan deductible
Ambulance
80% after plan deductible
80% of the Maximum Reimbursable Charge after plan deductible
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