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
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
Urgent Care Facility or Outpatient Facility
No charge after $50 per visit copay* No charge after $50 per visit copay*
*waived if admitted
*waived if admitted
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.)
No charge
No charge
No charge
No charge
No charge
No charge
Emergency Services
Physician’s Office Visit
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
Hospital Emergency Room
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.)
No charge
No charge
No charge
No charge
No charge
No charge
Air Ambulance
100%
100%
Ambulance
100%
100% of the Maximum Reimbursable Charge
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