SCHEDULE OF BENEFITS UNM Medical Plan UNM Health Extended Network Out-of-Network (Benefit Determination Network Benefits and Coverage Required) (1) ANNUAL PLAN YEAR DEDUCTIBLE Individual: $600(3) Individual: $1,800 (Deductible must be met for services Family: $1,200(3) Family: $3,600 subject to the deductible before benefits are paid) ANNUAL PLAN YEAR OUT-OF-POCKET Individual: $3,000 Individual: $7,500 MAXIMUM Family: $6,000 Family: $15,000 (Includes: Medical Deductible, (Includes: (Includes Medical Coinsurance Medical Deductible, Medical and Prescription Coinsurance, AND Medical and ONLY. Excludes Medical Coinsurance and Copayments) Prescription Copayments) Deductible and Prescription Copayments and Coinsurance) ANNUAL and MAXIMUM LIFETIME Unlimited BENEFIT Pre-Existing Condition Exclusion None PROVIDER/PRACTITIONER SERVICES Including: Non-specialist office visits – $25(2,3) Co-pay per $30(1,2,3) Co-pay per 40%(,5) Coinsurance (non-preventive) visit visit Specialist office visits – $35(2,3) Co-pay per $45(1,2,3) Co-pay per 40%(5) Coinsurance visit visit (non-preventive) Outpatient surgery Included in office Co-pay Included in office 40%(5) Coinsurance pay (In-Provider/Practitioner’s office) Allergy services Testing and Extract $55(2,3) Co-pay $55(1,2,3) Co-pay 40%(5) Coinsurance Injections Only (no office visit billed) No Co-pay(2) No Co-pay(1,2) 40%(5) Coinsurance Injections such as insulin, heparin and Included in office visit Included in office visit 40%(5) Coinsurance antibiotics Co-pay Co-pay Infertility services – diagnosing only $25(2,3) Co-pay per $30,(1,2,3) Co-pay per 40%(5) Coinsurance visit visit
SCHEDULE OF BENEFITS UNM Medical Plan Benefits and Coverage UNM Health Network Extended Network (Benefit Determination Required) (1) Out-of-Network ANNUAL PLAN YEAR DEDUCTIBLE (Deductible must be met for services subject to the deductible before benefits are paid) Individual: $600(3) Family: $1,200(3) Individual: $1,800 Family: $3,600 ANNUAL PLAN YEAR OUT-OF-POCKET MAXIMUM (Includes: Medical Deductible, Coinsurance, AND Medical and Prescription Copayments) Individual: $3,000 Family: $6,000 (Includes: Medical Deductible, Medical and Prescription Coinsurance and Copayments) Individual: $7,500 Family: $15,000 (Includes Medical Coinsurance ONLY. Excludes Medical Deductible and Prescription Copayments and Coinsurance) ANNUAL and MAXIMUM LIFETIME BENEFIT Unlimited Pre-Existing Condition Exclusion None PROVIDER/PRACTITIONER SERVICES Including: Non-specialist office visits – (non-preventive) $25(2,3) Co-pay per visit $30(1,2,3) Co-pay per visit 40%(,5) Coinsurance Specialist office visits – (non-preventive) $35(2,3) Co-pay per visit $45(1,2,3) Co-pay per visit 40%(5) Coinsurance Outpatient surgery (In-Provider/Practitioner’s office) Included in office Co-pay Included in office 40%(5) Coinsurance Allergy services Testing and Extract Injections Only (no office visit billed) $55(2,3) Co-pay No Co-pay(2) $55(1,2,3) Co-pay No Co-pay(1,2) 40%(5) Coinsurance 40%(5) Coinsurance Injections such as insulin, heparin and antibiotics Included in office visit Co-pay Included in office visit Co-pay 40%(5) Coinsurance Infertility services – diagnosing only $25(2,3) Co-pay per visit $30,(1,2,3) Co-pay per visit 40%(5) Coinsurance pay
Provider-Resource-Guide-2017-2018.docx