DEDUCTIBLE/OUT-OF-POCKET/PENALTIES

SUMMARY OF SERVICES

NETWORK PROVIDERS

NON-NETWORK PROVIDERS

Mandatory Hospital Pre-Admission and Outpatient Services Review Refer To The Section Entitled “Utilization Review Program”

Non-Compliance Penalty

Inpatient Services (Medical, Surgical, Behavioral)

25% up to $1,000

Surgical Procedures (Ambulatory)

25% up to $1,000

Ancillary Services

25% up to $1,000

Durable Medical Equipment

25% up to $1,000

Diagnostic Imaging (Ambulatory)

25% up to $1,000

Annual Maximum Benefit

Unlimited

Lifetime Maximum Benefit

Unlimited

Calendar Year Deductible

Individual

$5,000

$10,000

Family

$10,000

$20,000

Note: The Family Deductible Maximum includes covered expenses which are used to satisfy Deductibles for all family members combined.

Network Providers, and Non-Network Providers expenses will be applied equally toward the satisfaction of the Network Providers, and Non-Network Providers Deductible amounts.

Out-of-Pocket Maximum (including Deductible, Medical Co-payments, Prescription Drug Co-payments and Medical Co-insurance)

Individual

$6,350

$12,800

Family

$12,700

$25,600

Note: The Family Out-of-Pocket Maximum includes Out-of-Pocket expenses for all family members combined.

Network Providers and Non-Network Providers expenses will be applied equally toward the satisfaction of the Network Providers and Non-Network Providers Out- of-Pocket Maximums.