Pick the Network coinsurance level for facility and ancillary services.
| Facility/Ancillary | N1 | N2 |
|---|---|---|
| Coinsurance | 80% | 70% |
| Out-of-Pocket Maximum* Individual/Family |
$3,000/$9,000 |
$5,000/$15,000 |
| DEDUCTIBLE AND COINSURANCE APPLY TO THE FOLLOWING SERVICES: | ||
| Hospital Services** (Unlimited inpatient days) | 80% | 70% |
| Outpatient Surgery** | 80% | 70% |
| Skilled Nursing Facility** (120 days per cal. year) (Not waived if admitted from inpatient hospital stay) |
80% | 70% |
| Emergency Room (Not waived if admitted) | 80% | 70% |
| Outpatient Private Duty Nursing** (360 hours per cal. year) | 80% | 70% |
| Prosthetics and Durable Medical Equipment** | 50% | 50% |
| Lab/Pathology | 100% | 100% |
| X-Ray/Radiology/Diagnostics Routine Radiology MRI/MRA, CT Scans, PET Scans |
$40 $80 |
$40 $80 |
Coinsurance is based upon Plan allowance and reflects amount paid by the Plan.
* Only member coinsurance is applied to the out-of-pocket maximum.
** Pre-authorization required for certain services.