BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
The Percentage of Covered Expenses the Plan Pays See Definitions section for an explanation of Maximum Reimbursable Charge. Note: "No charge" means an insured person is not required to pay Coinsurance. Calendar Year Deductible Individual
80%
50%
$1,750 per person $3,500 per family
$3,500 per person $7,000 per family
Family Maximum
Family Maximum Calculation Individual Calculation:
Family members meet only their individual deductible and then their claims will be covered under the plan coinsurance; if the family deductible has been met prior to their individual deductible being met, their claims will be paid at the plan coinsurance. Combined Out-of-Pocket Maximum for Medical and Pharmacy expenses Individual
$4,250 per person $8,500 per family
$8,500 per person $17,000 per family
Family Maximum
Family Maximum Calculation Individual Calculation:
Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%; if the family Out-of-Pocket has been met prior to their individual Out-of- Pocket being met, their claims will be paid at 100%.
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