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
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
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