Pick network cost-sharing for facility and ancillary care.
| Facility/Ancillary | F1 | F2 | F3 | F4 |
|---|---|---|---|---|
| Hospital Services** | ||||
| (Unlimited inpatient days) | $0 | $100/day Max 5 days ($500) |
$150/day Max 5 days ($750) |
$250/day Max 5 days ($1,250) |
| Outpatient Surgery** | ||||
| $0 | $50 | $75 | $125 | |
| Skilled Nursing Facility** | ||||
| (120 days per cal. year*) (copay not waived if admitted from inpatient hospital stay) |
$0 | $50/day Max 5 days ($250) |
$75/day Max 5 days ($375) |
$125/day Max 5 days ($625) |
| Emergency Room | ||||
| (Copay not waived if admitted) | $100 | $100 | $100 | $100 |
| Outpatient Private Duty Nursing** | ||||
| (360 hours per cal. year*) | 90% | 90% | 85% | 85% |
| Prosthetics and Durable Medical Equipment** | ||||
| 70% | 70% | 50% | 50% | |
Coinsurance is based upon plan allowance and reflects amount paid by the plan.
* For AmeriHealth PPO and POS, combined in/out-of-network maximum.
** Preauthorization required for certain services.