2026-2027 Benefits Guide

Emergency Medical Transportation Outpatient Surgery Facility fee

100% after cal yr deductible

100% after cal yr deductible

30% coinsurance

30% coinsurance

(ambulatory surgery center) Physician/Surgeon Fees Facility fee (hospital room) Physician/Surgeon Fees Extended Care Services Home Health Care Hospital Stays

100% after cal yr deductible

30% coinsurance

50% coinsurance

30% coinsurance

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 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

Hospice Care 30% coinsurance Mental Health/Behavior Health/ Substance Abuse Services (Certain services must be preauthorized) Inpatient Services 30% coinsurance 50% coinsurance 30% coinsurance 30% coinsurance 50% coinsurance

$100 copay/visit Deductible does not apply

Outpatient Services (Office Visits) All other outpatient services Rehabilitation Services

50% coinsurance

30% coinsurance

30% coinsurance

50% coinsurance

30% coinsurance

$100 copay/visit Deductible does not apply $100 copay/visit Deductible does not apply $100 copay/visit Deductible does not apply

Physical Therapy

50% coinsurance

30% coinsurance

Speech, Hearing & Occupational Therapy

50% coinsurance

30% coinsurance

Chiropractic Care

50% coinsurance

30% coinsurance

If you are pregnant Office Visits

30% coinsurance

50% coinsurance

30% coinsurance

Childbirth/delivery professional services

30% coinsurance

50% coinsurance

30% coinsurance

Inpatient services

30% coinsurance

50% coinsurance

30% coinsurance

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