$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 Rehabilitation $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 [Complex Imaging Services See Definition $100 per procedure] N/A See Tier 2 [[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 (See definition below) Per Member $2,000 $4,400 Per Covered Family $4,000 $8,800] (Use above for separate accumulation.) [Maximum Out of Pocket Per [Calendar] [Plan] Year $2,000 $6,850 or amount permitted (See definition below) by 45 C.F.R. 156.130 Per Member $4,000
Extended Care and Rehabilitation [Complex Imaging Services See Definition [[All other] radiology services $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 $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 (See definition below) Per Member Per Covered Family (Use above for separate accumulation.) [Maximum Out of Pocket Per [Calendar] [Plan] Year (See definition below) Per Member $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] $6,850 or amount permitted by 45 C.F.R. 156.130
HMO%20EOC%202018%20A.docx