Primary Care Provider N/A See Tier 2 $30 Visits [when care is provided by the pre-selected PCP] $30 $50 Specialist Visits [and PCP visits if the PCP was not Pre-natal visits NONE NONE All Other Practitioner Visits N/A See Tier 2 $30 Hospital Confinement $300 per day up to $1500 per $500 per day up to $3000 per confinement; up to $3000 per confinement; up to $5000 per year year Extended Care and $300 per day up to $1500 per $500 per day up to $3000 per Rehabilitation confinement; up to $3000 per confinement; up to $5000 per year year [Complex Imaging Services $100 per procedure] N/A See Tier 2 See Definition [[All other] radiology services $75 per procedure] N/A See Tier 2 Laboratory Services NONE $30 per visit Emergency Room Visit $50 $100 Outpatient Surgery $100 $250 Inpatient Surgery $250 $500 Coinsurance (See definition below) Preventive Care NONE NONE Prescription Drugs N/A See Tier 2 50% [Generic Drugs] [10%] [Preferred Drugs] [20%] [Non-Preferred Drugs] [50%] Durable Medical Equipment N/A See Tier 2 50% [Maximum Out of Pocket Per [Calendar] [Plan] Year
Primary Care Provider Visits [when care is provided by the pre-selected PCP] Specialist Visits [and PCP visits if the PCP was not Pre-natal visits All Other Practitioner Visits Hospital Confinement Extended Care and Rehabilitation [Complex Imaging Services See Definition [[All other] radiology services N/A See Tier 2 $30 NONE N/A See Tier 2 $300 per day up to $1500 per confinement; up to $3000 per year $300 per day up to $1500 per confinement; up to $3000 per year N/A See Tier 2 N/A See Tier 2 $30 $50 NONE $30 $500 per day up to $3000 per confinement; up to $5000 per year $500 per day up to $3000 per confinement; up to $5000 per year $100 per procedure] $75 per procedure] Laboratory Services NONE $30 per visit Emergency Room Visit Outpatient Surgery Inpatient Surgery Coinsurance (See definition below) Preventive Care Prescription Drugs [Generic Drugs] [Preferred Drugs] [Non-Preferred Drugs] Durable Medical Equipment [Maximum Out of Pocket Per [Calendar] [Plan] Year $50 $100 $250 NONE N/A See Tier 2 N/A See Tier 2 $100 $250 $500 NONE 50% [10%] [20%] [50%] 50%