BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Preventive Care Note:
Includes coverage of additional services, such as urinalysis, EKG, and other laboratory tests, supplementing the standard Preventive Care benefit. Other Services Supplemental services, such as other common laboratory panel tests, when provided during a preventive visit. Routine Preventive Care - all ages Immunizations - all ages . Mammograms, PSA, PAP Smear Preventive Care Related Services (i.e. “routine” services) Diagnostic Related Services (i.e. “non-routine” services) . Inpatient Hospital – Facility Services
No charge No charge
In-Network coverage only In-Network coverage only
No charge
50% of the Maximum Reimbursable Charge after plan deductible Subject to the plan’s x-ray & lab benefit; based on place of service 50% of the Maximum Reimbursable Charge after plan deductible Limited to the semi-private room rate
Subject to the plan’s x-ray & lab benefit; based on place of service
80% after plan deductible
Semi-Private Room and Board
Limited to the semi-private room negotiated rate Limited to the semi-private room negotiated rate Limited to the negotiated rate
Private Room
Limited to the semi-private room rate
Special Care Units (ICU/CCU)
Limited to the ICU/CCU daily room rate
Outpatient Facility Services Operating Room, Recovery Room, Procedures Room, Treatment Room and Observation Room Inpatient Hospital Physician’s Visits/Consultations Inpatient Hospital Professional Services
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible
80% after plan deductible
Surgeon Radiologist Pathologist Anesthesiologist
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