BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Combined Medical/Pharmacy Out- of-Pocket Maximum Combined Medical/Pharmacy Out- of-Pocket: includes retail and home delivery drugs Home Delivery Pharmacy Costs Contribute to the Combined Medical/Pharmacy Out-of-Pocket Maximum Physician’s Services Primary Care Physician’s Office Visit Specialty Care Physician’s Office Visits OB/GYN providers will be considered either as a PCP or Specialist, depending on how the provider contracts with the Insurance Company. Surgery Performed in the Physician’s Office Second Opinion Consultations (provided on a voluntary basis) Consultant and Referral Physician’s Services Note:
Yes
Yes
Yes
In-Network coverage only
No charge after $30 per office visit copay No charge after $40 Specialist per office visit copay
50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible
No charge after the $30 PCP or $40 Specialist per office visit copay No charge after the $30 PCP or $40 Specialist per office visit copay No charge after either the $30 PCP or $40 Specialist per office visit copay or the actual charge, whichever is less
50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible
Allergy Treatment/Injections
Allergy Serum (dispensed by the Physician in the office) Convenience Care Clinic (includes any related lab and x-ray services and surgery)
No charge
No charge after the $30 per office visit copay
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