Emergency Room [$50] Copayment / visit; [$50]Copayment; waived if credited toward Inpatient admission occurs within 24 Copayment if admission hours; Deductible/Coinsurance occurs within 24 hours [Urgent Care [$30] Copayment/visit Deductible/Coinsurance] Immunizations and lead No Copayment, Deductible or Coinsurance screening for children Coinsurance Preventive Care No Copayment, Deductible or [Deductible/ Coinsurance] Coinsurance Orally administered Refer to the Covered Services Refer to the Covered Services cancer prescription drugs and Supplies and Covered and Supplies and Covered Charges sections Charges sections All other Prescription Drugs Deductible/Coinsurance Deductible/Coinsurance All other services and supplies Deductible/Coinsurance Deductible/Coinsurance Cash Deductible per [Calendar] [Plan] Year Network and Non-Network Per Member [amount not to exceed $2,000] [Per Covered Family [Dollar amount which is two times the individual Deductible.] ] Coinsurance Network [50% - 10%, in 5% increments] Non-Network [50% - 10%, in 5% increments] Network Maximum Out of Pocket Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Network and covered services and supplies in a [Calendar] [Plan] Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Network Maximum Out of Pocket. Once the Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Network or Non-Network covered services and supplies for the remainder of the [Calendar] [Plan] Year. The Network Maximum Out of Pocket for this Policy is as follows: Per Member per [Calendar] [Plan] Year [An amount not to exceed $[6,850 or amount permitted by 45 C.F.R. 156.130]]
Emergency Room [$50] Copayment / visit; credited toward Inpatient Copayment if admission occurs within 24 hours [$50]Copayment; waived if admission occurs within 24 hours; Deductible/Coinsurance [Urgent Care [$30] Copayment/visit Deductible/Coinsurance] Immunizations and lead screening for children No Copayment, Deductible or Coinsurance Coinsurance Preventive Care No Copayment, Deductible or Coinsurance [Deductible/ Coinsurance] Orally administered prescription drugs Refer to the Covered Services and Supplies and Covered Charges sections Refer to the Covered Services and Supplies and Covered Charges sections All other Prescription Drugs Deductible/Coinsurance Deductible/Coinsurance All other services and supplies Deductible/Coinsurance Deductible/Coinsurance Cash Deductible per [Calendar] [Plan] Year Network and Non-Network Per Member [amount not to exceed $2,000] [Per Covered Family [Dollar amount which is two times the individual Deductible.] ] Coinsurance Network [50% - 10%, in 5% increments] Non-Network [50% - 10%, in 5% increments] Network Maximum Out of Pocket Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Network and covered services and supplies in a [Calendar] [Plan] Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Network Maximum Out of Pocket. Once the Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Network or Non-Network covered services and supplies for the remainder of the [Calendar] [Plan] Year. The Network Maximum Out of Pocket for this Policy is as follows: Per Member per [Calendar] [Plan] Year [An amount not to exceed $[6,850 or amount permitted by 45 C.F.R. 156.130]] cancer
HMO%20POS%20EOC%202018%20A.docx