BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
80% after plan deductible
50% after plan deductible
Inpatient Hospital - Facility Services
Semi-Private Room and Board
Limited to the semi-private room negotiated rate Limited to the semi-private room negotiated rate
Limited to the semi-private room rate
Private Room
Limited to the semi-private room rate
Special Care Units (ICU/CCU)
Limited to the ICU/CCU daily room rate
Limited to the negotiated rate
Outpatient Facility Services Operating Room, Recovery Room, Procedures Room, Treatment Room and Observation Room
80% after plan deductible
50% after plan deductible
80% after plan deductible
50% after plan deductible
Inpatient Hospital Physician’s Visits/Consultations
80% after plan deductible
50% after plan deductible
Inpatient Hospital Professional Services
Surgeon Radiologist Pathologist Anesthesiologist
80% after plan deductible
50% after plan deductible
Outpatient Professional Services
Surgeon Radiologist Pathologist Anesthesiologist
Urgent Care Services
Physician’s Office Visit
80% after plan deductible
80% after plan deductible
Urgent Care Facility or Outpatient Facility 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.)
80% after plan deductible
80% after plan deductible
80% after plan deductible
80% after plan deductible
80% after plan deductible
80% after plan deductible
80% after plan deductible
80% after plan deductible
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