BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Emergency Services
Physician’s Office Visit
80% after plan deductible
80% after plan deductible
Hospital Emergency Room
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.)
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
80% after plan deductible
80% after plan deductible
Ambulance
80% after plan deductible
50% after plan deductible
Inpatient Services at Other Health Care Facilities Includes Skilled Nursing Facility, Rehabilitation Hospital and Sub- Acute Facilities Calendar Year Maximum: 90 days combined . Laboratory and Radiology Services (includes pre-admission testing) Physician’s Office Visit
80% after plan deductible
50% after plan deductible
Outpatient Hospital Facility
80% after plan deductible
50% after plan deductible
Independent X-ray and/or Lab Facility
80% after plan deductible
50% after plan deductible
Advanced Radiological Imaging (i.e. MRIs, MRAs, CAT Scans and PET Scans) Physician’s Office Visit
80% after plan deductible
50% after plan deductible
Inpatient Facility
80% after plan deductible
50% after plan deductible
Outpatient Facility
80% after plan deductible
50% after plan deductible
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