INDIVIDUAL PAYMENT SUMMARY

IN-NETWORKOUT-OF-NETWORKSELECTHEALTH NETWORK DEDUCTIBLE AND OUT-OF-POCKET MAXIMUM4,5IN-NETWORKOUT-OF-NETWORK$8,550 $17,100 $8,550 $85,500 $8,550/$17,100$17,100/$34,200$8,550/$17, 100$85,500/$171,000 INPATIENT SERVICES3IN-NETWORKOUT-OF-NETWORK Medical, Surgical, Hospice, Emergency AdmissionsCovered 100% after Deductible50% after Deductible Skilled Nursing FacilityCovered 100% after Deductible50% after DeductibleUp to 30 days/calendar Year Rehab/Habilitative Therapy: Physical, Speech, OccupationalCovered 100% after Deductible50% after Deductible PROFESSIONAL SERVICES3IN-NETWORKOUT-OF-NETWORK Office Visits and Office Surgeries Primary Care Provider (PCP)1 Secondary Care Provider (SCP)1$90 50% after Deductible Allergy Tests See office visitsSee office visits Allergy Treatment and SerumCovered 100%50% after Deductible Physician's Fees - Medical, Surgical, Maternity, AnesthesiaCovered 100% after Deductible50% after Deductible preventive CARE AS OUTLINED BY THE ACA2IN-NETWORKOUT-OF-NETWORK Office Visits (PCP/SCP)1 Covered 100%50% after Deductible Adult and Pediatric ImmunizationsCovered 100%50% after Deductible Diagnostic Tests: Minor Covered 100%50% after Deductible Other preventive ServicesCovered 100%50% after Deductible VISION SER

Jan 01, 2021 · PREVENTIVE CARE AS OUTLINED BY THE ACA 2 IN-NETWORK OUT-OF-NETWORK Office Visits (PCP/SCP)1 Covered 100% 50% after Deductible Adult and Pediatric Immunizations Covered 100% 50% after Deductible Diagnostic Tests: Minor Covered 100% 50% after Deductible Other Preventive Services Covered 100% 50% after Deductible VISION …

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