Second Surgical opinion NONE NONE Maternity care (pre-natal NONE NONE visits) Prescription Drugs [$250] [Generic Drugs] [$50] [Preferred Drugs] [$100] [Non-Preferred Drugs] [$150] [All other Covered Charges Per Covered Person $1,000 $1,500 Per Covered Family $2,000 $3,000] (Use above deductible for separate accumulation..) [All other Covered Charges Per Covered Person $1,000 $2,500 Per Covered Family $2,000 $5,000 (Use above if Tier 1 deductible can be satisfied independently; Tier 1 accumulates toward Tier 2) Copayment applies after the Cash Deductible is satisfied Preventive Care NONE NONE Primary Care Provider N/A See Tier 2 $30 Tier 1 Tier 2 Services Visits [when care is provided by the pre-selected PCP] $30 $50 Specialist Visits [and PCP visits if the PCP was not Maternity Care (Pre-natal NONE NONE visits) All Other Practitioner Visits N/A See Tier 2 $30 Hospital Confinement $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 $300 per day up to $1500 per $500 per day up to $3000 per confinement; up to $3000 per confinement; up to $5000 per Rehabilitation
Second Surgical opinion Maternity care (pre-natal visits) NONE NONE NONE NONE Prescription Drugs [Generic Drugs] [Preferred Drugs] [Non-Preferred Drugs] [$250] [$50] [$100] [$150] [All other Covered Charges Per Covered Person Per Covered Family (Use above deductible for separate accumulation..) [All other Covered Charges Per Covered Person Per Covered Family (Use above if Tier 1 deductible can be satisfied independently; Tier 1 accumulates toward Tier 2) Copayment applies after the Cash Deductible is satisfied $1,000 $2,000 $1,000 $2,000 $1,500 $3,000] $2,500 $5,000 Preventive Care Primary Care Provider Services Visits [when care is provided by the pre-selected PCP] Specialist Visits [and PCP visits if the PCP was not Maternity Care (Pre-natal visits) All Other Practitioner Visits Hospital Confinement Extended Care and Rehabilitation NONE N/A See Tier 2 Tier 1 $30 NONE N/A See Tier 2 $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 NONE $30 Tier 2 $50 NONE $30 $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
planA50_D.docx