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Pti oMf nae5hield
<br /> inesot $1 ,200 CDHP !d ,m °,''. <'n'.,-.,4,',',
<br /> THIS IS ONLY A SUMMARY AND IS SUBJECT TO THE TERMS OF THE CONTRACT**
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<br /> `rwa 451i :, ,, ` vt; Out of Network
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<br /> ,litt-dsrt•salf-dsfar, tat- -AL_y't ,, 3 r+»k ,J n '. l"/-s tnlr., "'R'tmrty �t[]e�SfPeU. :-
<br /> Calendar Year Deductible Saff i r "e '�Gjay'i a y eraw r
<br /> Calendar Year Out-of-Pocket Maximum ittg ..i '4: Pti l, ,
<br /> 1 he in and out-of-net,.crk maximums �_ ' n CW_ t 4 , f ,, Medical and Prescription
<br /> Cross.ripply rte' r a „.y,a54.1 h-a1# t ;V ,I $3,500 Single $6,500 Family
<br /> tvar.-eon r red r ha gr and ch-r,I ir. g"� '11*P ir}}t°., 't, ,� .
<br /> a ss t C ui allo rer' amount do not S y` -LIT;Cp' { i '#° T
<br /> apply in the mbof-tr r ket maximum p' r „u ..amr. 41¼ , e,�fi j , a .
<br /> Coinsurance `fl Tt ,. LeL ri a+'U , " 80%
<br /> �1/44 fia+ If non-participating provider services are
<br /> p;a" , °, a covered,you are responsible for the
<br /> • e+to .At°F ,i'91-M difference between the billed charges and
<br /> Benefit Payment Levels f{T"ttT.. - ,w '+ 'i t ``l`t'* allowed amount. Most payments are
<br /> }C i " ° -1 ;. based on allowed amount.
<br /> Lifetime Maximum per Person yrtli`tr1T ',' 194Ffigt.F " 1 t
<br /> Dependent Child Age Limit To age 26 through the calendar month of the birthday
<br /> COVERED CHARGES
<br /> Preventive Care
<br /> • Well Child Care through age b ,m >e n =r i : �w ' n r ; (Mt. 100/
<br /> • Prenatal Care �a,�rr I•i? ' s .r r#�za � ,i i :�=
<br /> • t #"h
<br /> Routine F'I ysicals ages 6 and olCer i t ts' 01 � ,. a °,
<br /> 0li.c Vint. ➢, , eat i ` , 4 $ ' [1 t , a° .
<br /> •
<br /> t � g z
<br /> • Cancel Screening a 4 ° Ws i ` Deductible then 80%coinsurance.
<br /> • Routine Hearing and Vision Exams a pi p • , 1� „x, `r
<br /> a
<br /> • Immunizations and Vaccinations ,, 1 -n ,° 1.='
<br /> Ph sician Services
<br /> • In Hosp'tal Medical Visits ' ^ Yy . ,
<br /> • Surgery and Anesthesia yGkfbleFN#en 100°t^g, n�,ur Deductible then 80%coinsurance.
<br /> • Inpatient lab and Xrays.etc ', _, wax a -,+ten
<br /> e .
<br /> • Office Visits due to Illness or ct
<br /> Injury bl Deductible then 80%coinsurance.
<br /> • Urgent Care (Clinic Based �eUf i thgn 1qps. " +rt t i• Outpatient Lab and X-ray kit*udlb`Cl theii,100%tco` "spraFl Deductible then 80%coinsurance.
<br /> • Allergy Injections and Serum i 'u° Jgfh,Brj 1'gq°3or� fns -',T t' Deductible then 80%coinsurance.
<br /> Other Professional Services
<br /> • Chiropractic Care Deductible then 1004 coitsuti nee. Deductible then 80%coinsurance
<br /> -•udihle then 100%comst{ratice.
<br /> • Hans I Icalth Care - Deductible then 80%coinsurance.
<br /> • Physical Therapy, Occupational
<br /> Therapy Speech Therapy .'Deductible then 100%winsurance- Deductible then 80%coinsurance
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