2023-2024 Benefits Guide

$500 copay plus 30% coinsurance

$500 copay plus 30% coinsurance

100% after cal yr deductible

100% after cal yr deductible

Emergency Room Care

Non-Emergency Situations (Preauthorization required) Facility Charges (Hospital room) 30% coinsurance

100% after cal yr deductible

50% coinsurance

30% coinsurance

Physician/Surgeon Charges

Emergency Medical Transportation

100% after cal yr deductible

100% after cal yr deductible

30% coinsurance

30% coinsurance

Facility Fee

Out-Patient Ambulatory Surgery Center In-Patient Hospital Room Extended Care Services Home Health Care

100% after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible 100% after cal yr deductible

30% coinsurance

50% coinsurance

30% coinsurance

30% coinsurance

50% coinsurance

30% coinsurance

30% coinsurance

50% coinsurance

30% coinsurance

Skilled Nursing Facility

No Charge; deductible does not apply

Hospice Care

50% coinsurance

30% coinsurance

Mental Health/Behavior Health/ Substance Abuse Services Inpatient Services 30% coinsurance

50% coinsurance

30% coinsurance

Outpatient Services (Office Visits) All other outpatient services

$45 copay

50% coinsurance

30% coinsurance

30% coinsurance

50% coinsurance

30% coinsurance

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