Includes medical, mental health and maternity services.
|
Inpatient Service |
In-Network Provider1, 2, 3 |
Non-network Provider2, 4 |
|
Semi-Private Room |
Pays 90% of network rates |
50% of non-network rates |
|
Lab Tests, X-rays & Imaging |
Pays 90% of network rates |
50% of non-network rates |
|
General supplies |
Pays 90% of network rates |
50% of non-network rates |
|
Nursing services |
Pays 90% of network rates |
50% of non-network rates |
|
Medication |
Pays 90% of network rates |
50% of non-network rates |
|
Physicians & Specialists |
Pays 90% of network rates |
50% of non-network rates |
|
Surgery |
Pays 90% of network rates |
50% of non-network rates |
1Inpatient admissions: $250 co-pay per inpatient admission.
2Inpatient hospital services are subject to the $450 deductible (per plan year).
3Covered medical expenses incurred for the treatment of hypertension, diabetes, and pre/cervical cancer with network providers are not subject to the deductible, copay, or coinsurance.
4Inpatient hospital services with non-network providers are subject to a $500 co-pay per inpatient admission.
Note: Inpatient hospital care in connection with childbirth will be covered for at least 48 hours following a normal delivery (96 hours following a cesarean section).