Annual Medical After DEDUCTIBLE: 100% except as After DEDUCTIBLE: COINSURANCE 90%/10% applies to described below for: 90%/10% applies to medical services except DURABLE MEDICAL medical services except for office visits, and as EQUIPMENT, cochlear for office visits, and as described below. implants and hearing described below. COINSURANCE applies aids. Then, 80% to COINSURANCE applies to Out-of-Pocket-Limit OOPL. to OOPL except as (OOPL) except as described below. described below. Annual Medical $1,250 None except as After DEDUCTIBLE: OOPL PARTICIPANT/$2,500 described below for: $2,500 per individual plan aggregate family limit DURABLE MEDICAL $5,000 per family plan except as described EQUIPMENT, cochlear except as described below.1 implants and hearing below. aids. Then, 80% to OOPL. 1 Routine, preventive 100% 100% 100% services as required by federal law Primary Care Office $15, DEDUCTIBLE need No medical After DEDUCTIBLE: $15 Visit COPAYMENT not be met first COPAYMENTs Primary Care Office Visit applies to: Family Practice COPAYMENT applies COPAYMENT applies General towards meeting the towards meeting the Practice annual OOPL, but not the annual OOPL Internal DEDUCTIBLE Medicine Midwives Nurse Practitioners Physician Assistants Chiropractic Mental Health Physical Therapy Occupational Therapy Speech Therapy Specialist $25 per visit, No medical After DEDUCTIBLE: $25 COPAYMENT DEDUCTIBLE need not COPAYMENTs per visit Applies to: be met first Specialists
Annual Medical COINSURANCE After DEDUCTIBLE: 90%/10% applies to medical services except for office visits, and as described below. COINSURANCE applies to Out-of-Pocket-Limit (OOPL) except as described below. 100% except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. After DEDUCTIBLE: 90%/10% applies to medical services except for office visits, and as described below. COINSURANCE applies to OOPL except as described below. Annual Medical OOPL $1,250 PARTICIPANT/$2,500 aggregate family limit except as described below.1 None except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. 1 After DEDUCTIBLE: $2,500 per individual plan $5,000 per family plan except as described below. Routine, preventive services as required by federal law 100% 100% 100% Primary Care Office Visit COPAYMENT applies to: Family Practice General Practice Internal Medicine Midwives Nurse Practitioners Physician Assistants Chiropractic Mental Health Physical Therapy Occupational Therapy Speech Therapy $15, DEDUCTIBLE need not be met first COPAYMENT applies towards meeting the annual OOPL, but not the DEDUCTIBLE No medical COPAYMENTs After DEDUCTIBLE: $15 Primary Care Office Visit COPAYMENT applies towards meeting the annual OOPL Specialist COPAYMENT Applies to: Specialists $25 per visit, DEDUCTIBLE need not be met first No medical COPAYMENTs After DEDUCTIBLE: $25 per visit
Exhibit1-PBP_Agreement_Rev01-04-2017_clean.docx