Medical Coverage - Out of Network Coverage

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» Plan Year Out-of-Pocket Maximum
» Office Visits
» Plan Year Deductible
» Co-Insurance
» Exceptions
» Additional Medical Coverage Details
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Additional Coverage Details:

» Prescription Coverage
» Preventive Services
» Out of Network Coverage
» MDLIVE - Telehealth
» CatapultHealth - Health Screenings
» Benefits Value Advisor
» ConnectDME - Medical Equipment
» Dependent Deductible Reimbursement
» Dependent Accident Reimbursement
» Medical Claim Reimbursement Form
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Resources

» Provider Search: Click Here
» Video: Watch
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Plan Year Out-of-Network Out-of-Pocket Maximum

4,000
» $12,000 Maximum for a Family of 3 or More
»  IMPORTANT! Amounts paid for In-Network coverage do not count towards Out-of-Network coverage and vice versa
» No Lifetime
» No Plan Year Limits
» 100% of Allowable Charges are Plan Paid once Plan Year Out-of-Pocket Maximum is Reached
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Out-of-Pocket Maximum is Reached with any Combination of the Following:

Out-of-Network Office Visits

No Coverage Available
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Plan Year Out-of-Network Deductible

750
» Counts Towards the Annual Out-of-Network Out-of-Pocket Maximum
» $2,250 Maximum for a Family of 3 or More
»  IMPORTANT! Amounts paid for In-Network coverage do not count towards Out-of-Network coverage and vice versa
» $250 Employee & Spouse Deductible Reduction: Learn More
» $375 Dependent Deductible Reimbursement: Learn More
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Out-of-Network Co-Insurance

30 %
» Member Paid of Allowable Charges After Plan Year Deductible
» Member Responsible for 100% of Billed Charges in-excess of the Allowable (In-Network) Amount (known as “Balance Billing”)
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Exception

ER Claims
» Paid as In-Network if Claim is for Emergency Services
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