Except as specifically stated for EMERGENCY and URGENT CARE (see Sections and ), YOU do not have coverage for services from OUT-OF-NETWORK PROVIDERS unless YOU receive a PRIOR AUTHORIZATION from YOUR TPA before such services are obtained. The covered benefits are subject to the following: DEDUCTIBLES, COINSURANCE and COPAYMENTS as described in this schedule: Benefit: State of Eligible PARTICIPANTS MEDICARE prime High DEDUCTIBLE Wisconsin who are not eligible for PARTICIPANTS Health Plan for eligible nor enrolled in PARTICIPANTS 3 MEDICARE as the primary payor3 Annual Medical $250 Individual/$500 None The DEDUCTIBLE must be met before coverage begins. DEDUCTIBLE Family The DEDUCTIBLEs are:$1,500 per individual When an individual within plan a family plan meets the $3,000 per family plan $250 DEDUCTIBLE, DEDUCTIBLE includes COINSURANCE will apply prescription drugs and to covered medical applies to services. Limit (OOPL). Medical DEDUCTIBLE does not apply to office visit COPAYMENTS or prescription drugs.
Except as specifically stated for EMERGENCY and URGENT CARE (see Sections and ), YOU do not have coverage for services from OUT-OF-NETWORK PROVIDERS unless YOU receive a PRIOR AUTHORIZATION from YOUR TPA before such services are obtained. The covered benefits are subject to the following: DEDUCTIBLES, COINSURANCE and COPAYMENTS as described in this schedule: Benefit: State of Wisconsin Eligible PARTICIPANTS who are not eligible for nor enrolled in MEDICARE as the primary payor3 MEDICARE prime PARTICIPANTS High DEDUCTIBLE Health Plan for eligible PARTICIPANTS 3 Annual Medical DEDUCTIBLE $250 Individual/$500 Family When an individual within a family plan meets the $250 DEDUCTIBLE, COINSURANCE will apply to covered medical services. Medical DEDUCTIBLE does not apply to office visit COPAYMENTS or prescription drugs. None The DEDUCTIBLE must be met before coverage begins. The DEDUCTIBLEs are:$1,500 per individual plan $3,000 per family plan DEDUCTIBLE includes prescription drugs and applies to (OOPL). Limit
Exhibit1-PBP_Agreement_Rev01-04-2017_clean.docx