|
REGULAR
PLAN PPO |
LOW
OPTION PLAN
(For COBRA Participants and Extended Coverage Participants Only) |
|
NETWORK
PROVIDER |
NON-NETWORK
PROVIDER |
OUT
OF AREA
(For participants residing outside the PPO service area only) |
NETWORK
PROVIDER |
NON-NETWORK
PROVIDER |
| HOSPITAL
SERVICES |
| Inpatient
Services 1 |
85%
after $100 copay/
admission |
70%
after $100 copay/
admission |
80%
after $100 copay/
admission |
70%
after $100 copay/
admission |
60%
after $100 copay/
admission |
| Outpatient
Services |
85% |
70% |
80% |
70% |
60% |
|
Outpatient
Lab Work and X-rays
|
85%
|
70%
|
80%
|
70%
|
60%
|
| Emergency
Room |
85%
after $50 copay (copay is waived if admitted; hospital admission copay
applies) |
70%
after $50 copay (copay is waived if admitted; hospital admission copay
applies) |
80%
after $50 copay (copay is waived if admitted; hospital admission copay
applies) |
70%
after $50 copay (copay is waived if admitted; hospital admission copay
applies) |
60%
after $50 copay (copay is waived if admitted; hospital admission copay
applies) |
1. Includes
semi-private room and board within plan limits and ancillary services.
|
