BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Abortion Includes only non-elective procedures Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
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
Inpatient Facility
80% after plan deductible
Outpatient Facility
80% after plan deductible
Physician’s Services
80% after plan deductible
Women’s Family Planning Services Office Visits, Lab and Radiology Tests and Counseling Note: Includes coverage for contraceptive devices (e.g., Depo-Provera and Intrauterine Devices (IUDs)) as ordered or prescribed by a physician. Diaphragms also are covered when services are provided in the physician’s office. Surgical Sterilization Procedures for Tubal Ligation (excludes reversals) Physician’s Office Visit
No charge
50% of the Maximum Reimbursable Charge after plan deductible
No charge
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
Inpatient Facility
No charge
Outpatient Facility
No charge
Physician’s Services
No charge
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