(Use above deductible for separate accumulation..) [All other Covered Charges $1,000 $2,500 Per Covered Person $2,000 $5,000 Per Covered Family (Use above if Tier 1 deductible can be satisfied independently; Tier 1 accumulates toward Tier 2) applies after the Copayment 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 year year $100 per procedure] N/A See Tier 2 [Complex Imaging Services See Definition $75 per procedure] N/A See Tier 2 [[All other] radiology services Laboratory Services NONE $30 per visit Emergency Room Visit $50 $100 Outpatient Surgery $100 $250
(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 $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 [Complex Imaging Services See Definition [[All other] radiology services 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 year N/A See Tier 2 N/A See Tier 2 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 year $100 per procedure] $75 per procedure] Laboratory Services NONE $30 per visit Emergency Room Visit Outpatient Surgery $50 $100 $100 $250
A50_D_2017%20A.docx