confinement; up to $3000 per confinement; up to $5000 per year year $300 per day up to $1500 per $500 per day up to $3000 per Extended Care and confinement; up to $3000 per confinement; up to $5000 per Rehabilitation year year $100 per procedure] N/A See Tier 2 [Complex Imaging Services See Definition $75 per procedure] N/A See Tier 2 [[All other] radiology services 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 Year (See definition below) Per Covered Person $2,000 $4,400 Per Covered Family $4,000 $8,800] (Use above for separate accumulation.) [Maximum Out of Pocket Per calendar Year (See definition below) Per Covered Person $2,000 $6,600 or amount permitted by 45 C.F.R. 156.130 Per Covered Family $4,000 $13,200 or 2X per person
Extended Care and Rehabilitation [Complex Imaging Services See Definition [[All other] radiology services 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 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 Year (See definition below) Per Covered Person Per Covered Family (Use above for separate accumulation.) [Maximum Out of Pocket Per calendar Year (See definition below) Per Covered Person Per Covered Family $50 $100 $250 NONE N/A See Tier 2 N/A See Tier 2 $2,000 $4,000 $2,000 $4,000 $100 $250 $500 NONE 50% [10%] [20%] [50%] 50% $4,400 $8,800] $6,600 or amount permitted by 45 C.F.R. 156.130 $13,200 or 2X per person