Hospital Charges |
90% coinsurance after deductible in-network, 50% out-of-network after deductible |
100% after $300 copay in-network, no coverage out-of-network |
After deductible: 80% in-network, 50% out-of-network |
After deductible: 70% in-network, 50% out-of-network |
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Emergency Ambulance Service |
90% coinsurance after deductible in-network, 50% out-of-network after deductible |
After deductible, 100% in-network, no coverage out-of- network |
After deductible: 80% in-network, 50% out-of-network |
After deductible: 70% in-network, 50% out-of-network |
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Semi-Private Room |
90% coinsurance after deductible in-network, 50% out-of-network after deductible |
100% after $300 copay in-network, no coverage out-of-network |
After deductible: 80% in-network, 50% out-of-network |
After deductible: 70% in-network, 50% out-of-network |
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Intensive Care |
90% coinsurance after deductible in-network, 50% out-of-network after deductible |
100% after $300 copay in-network, no coverage out-of-network |
After deductible: 80% in-network, 50% out-of-network |
After deductible: 70% in-network, 50% out-of-network |
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Surgery and Anesthesia |
90% coinsurance after deductible in-network, 50% out-of-network after deductible |
After deductible, 100% in-network, no coverage out-of- network |
After deductible: 80% in-network, 50% out-of-network |
After deductible: 70% in-network, 50% out-of-network |
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X-ray and Diagnostic Services |
90% coinsurance after deductible in-network, 50% out-of-network after deductible |
After deductible, 100% in-network, no coverage out-of- network |
After deductible: 80% in-network, 50% out-of-network |
After deductible: 70% in-network, 50% out-of-network |
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Blood and/or Plasma |
90% coinsurance after deductible in-network, 50% out-of-network after deductible |
After deductible, 100% in-network, no coverage out-of- network |
After deductible: 80% in-network, 50% out-of-network |
After deductible: 70% in-network, 50% out-of-network |
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Emergency Room |
100% after $150 copay in or out-of-network |
100% after $150 copay in or out-of-network |
After deductible: 80% in-network, 50% out-of-network |
After deductible: 70% in-network, 50% out-of-network |
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Delivery of Baby |
90% coinsurance after deductible in-network, 50% out-of-network after deductible |
After deductible, 100% in-network, no coverage out-of- network |
After deductible: 80% in-network, 50% out-of-network |
After deductible: 70% in-network, 50% out-of-network |
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