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BENEFITS SUMMARY

In-Network Plan Benefits

In-Network benefits are subject to a copay when you visit a physician for service. The copay amounts are as follows:

  • $25 for a Primary Care Physician (PCP) or an in-store health clinic;
  • $40 when you visit a Specialist;
  • $15 for Psychological Counseling; and
  • $50 for Hospital Emergency Room visits, but this copay will be waived if the individual is admitted.

Other medical treatment is subject to a $400 deductible (but no more than $700 per family) during the calendar year. Thereafter, such expenses will be coinsured with you paying 30% of the cost. Except for counseling visits, behavioral health services are coinsured with you paying 30% of the cost.

When you are hospitalized in an In-Network hospital, you will pay a copay of $350 and then 30% of the remaining cost. If you are hospitalized an additional time during the year or if any other family member is hospitalized, a second $350 copay will not apply for that year.

Visits to the emergency room of an In-Network hospital for routine (non-emergency) medical treatment are not covered. Your total out-of-pocket cost for deductible and coinsurance expenses is limited to no more than $5,000 per individual in medical expenses and $5,000 per individual in behavioral health expenses. There is no out-of pocket limit for the family.

Visits to the emergency room of an In-Network hospital for routine (non-emergency) medical treatment are not covered.

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