year year $100 per procedure] [Complex Imaging Services 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 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 $6,850 or amount permitted by 45 C.F.R. 156.130 Per Covered Family $4,000 $13,200 or 2X per person Use above if Tier 1 MOOP amount] can be satisfied independently; Tier 1 accumulates toward Tier 2)
[Complex Imaging Services See Definition [[All other] radiology services year N/A See Tier 2 N/A See Tier 2 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 Use above if Tier 1 MOOP can be satisfied independently; Tier 1 accumulates toward Tier 2) $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 $13,200 or 2X per person amount]
planA50_D.docx