![]() The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network. Only the terms and conditions of coverage benefits listed in the policy are binding. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. The information shown here is a summary of benefits for informational purposes only. Out-of-Network Annual Out-of-Pocket LimitĮlectronic Signature for Application Available $50 Copay, limited to 20 Visit(s) per Yearĥ0% Coinsurance, limited to 1000 Dollars per Year No Charge, limited to 1 Visit(s) per Year Inpatient Hospital Services: 20% Coinsurance after deductible Inpatient Physician and Surgical Services: 20% Coinsurance after deductibleĢ0% Coinsurance after deductible, limited to 90 Days per YearĢ0% Coinsurance after deductible, limited to 42 Visit(s) per Year Outpatient Rehabilitation Services (PT, OT, ST)Ģ0% Coinsurance after deductible, limited to 60 Visit(s) per Year Outpatient Lab: $25 Copay X-rays: $60 Copay Outpatient Surgery Physician/Surgical Services: 20% Coinsurance after deductible Outpatient Facility Fee: 20% Coinsurance after deductible Generic Drugs: $22.60 Copay Preferred Brand Drugs: $50 Copay Non-Preferred Brand Drugs: 30% Coinsurance after deductible Specialty Drugs: 30% Coinsurance after deductible Off Label Prescription Drugs: 30% Coinsurance after deductible Office Visit for Other Practitioner (Nurse, Physician Assistant) Office Visit for Primary Doctor Find Doctors
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |