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�����r ��-�{ <br /> HEALTH Xl'�(Si3RAl"�CE PLAN HIGHLIGHTS-EFFEC"T1VE 1/1120z0 <br /> MAJBR PL.AN E�.EMENTS Plan PJ10t35 F'tan PJ1t109 RE4437 <br /> Deciuctible: <br /> Single�in netwark i out of network) $250/SSqt) �fi50/$1,500 51.5001�3*000 <br /> FamNytpersan{#n!out a#neirvortc} �75t?f�1�500 $2.25U/9'r4�50t3 �2�7t101�4,500 <br /> Max Out-o#-Pocket L'smit; <br /> Single(In network i aut of nerivohc) 52.000/9'►4.00p �3,OQ0/S6�OU0 �3.000 C Y�,C100 <br /> F'amityhnax(In neiworkJvut afi netwock) $4�t?00 t�8,000 56,04Qf$12.000 $7,150/$22.504 <br /> PREMlUM CON7RIBUTION3 <br /> Birnanthl deduction <br /> SiNGI.E Coverage $36A0 ffi14.5Q $S.Ot} <br /> EMP+SPQUS�Cave�age �?5.50 $35.5U $t8.0Q <br /> EMP+CHlLC►REN Coverage $72,Ot! $34.50 $�f 7.54 <br /> FAMtf.Y Caverege $f 12.Ot3 $52.50 $26.50 <br /> CpVERAG��'OR ALL PLANS IN NETWORK <br /> Hnspita!benefit—lnpetienUQuipatte�t 8096 s�ter deciuctiWe 8096 afier dacEuctik�e 8t}%aiter deductit�le <br /> Physician Service.4 $20 oopay <br /> In Network 80°�6 after deductib(e Deductible daes not eppty �6 after d�dudib�e <br /> I <br /> Emergency Care •"'$150 r,�pay for nan- •••Si50 crapay for r�or�- 80°�after ded. i � <br /> err� erste enc I � <br /> Preventive Care: <br /> Evidence-based itams/senrices rated 100°r6 10Q°10 1� <br /> A ar B as recommendect by U.S. deducfik�cioes nat appiy deductibie ck�es nat apply dsducii6�e c�es�ot � i <br /> Preventiv�5erv�es Task Force �PP� � <br /> I <br /> Sta�eneric�S2U Famulary, <br /> Prescription Medicines(reteiij �ia��"���q��'ry" � I <br /> �5it ldon-Fom�ary,�StI 35U Nfwi-Fattnuiary.$BU efter deducG'ble � <br /> 3peciatty � I <br /> Prescription Medicines: Individua{-�1.+C1�1 individua!-51,004 IncNuded w! � <br /> Out-af ket ex se 6mit Famt -�3 Q{i0 Fami -$3 OOCl Medicat � <br /> Prh+ete duty nursing 8Q96 efter deduc;Uble 80%after deduc�ible 8�196 after deductible � <br /> 60 vis�s per cater�lsr ysar 60 vis�ss per caiendar y+ear 6C3 visits per ceiendar � <br /> ear I <br /> PhysicaUOa�Raqor�aYSpeech 8090 efter deduc:tibie 80%efter dedus:tible 80°r6 sRer deduc�ible � <br /> therapy �0 cor►tibined visits per 60 c�ombined visit�per 60 oanbirred visits�er I <br /> catendsr year c�enda�year catendar ear � <br /> Chiropract� 25 vi��s per catendar 25 visits pe�ceiendar ' <br /> year 25 visi�s per celender year year � <br /> Prec;e�tificat�n Fa�une trr pre-certiEy may result in a reciuctiur►in benefits when recefving inpatient � <br /> sen+ices ! <br /> NOTE: T't�e above ehart r�presents aniy e summauy af ptan i�n�fits�nd nelated informadar^r,and is pra�vided iarr iilusUative purposes ayty. IC is rwt ' <br /> intended as a s�stltute!`a tf�plan dacctm�erzt. Fc�cktaited i�mation e�n ptan ber�ts,arnditksns,fimlta6ons,and ez�t�siorts,picase refer to tfie <br /> pian dt�cument. <br /> �'Emerger+cY Raom�i�l Copaymer�t(waFved�adnnit�ec#ta tf�e HospihN;i a�an InpatieM innmediat+�iy Eallowing�r�qee�y tr�ratn�a�t er if vi�it <br /> �amergent as psr ttwe definition belaMt}. <br /> MERGEN7 MEDtCAt.CARE means senr�es�ed.r�td�may have�ae at�patleirt�diag�wstic s�snrlr;es,but ern af a rr�l c�nd�ian <br /> SPlayin9 kseH thrsx�gh�cute symptams M st�ft'icierd severity(indud�Q se+�'e i�t?sruuch that a prudent layper�an,who sn a+v�ape knowledpe <br /> `hsaith and m�d'�c3�,couid reasonably e�t tfiat dwe sb�enoe of Immediate medicat atter�tion couid resutt i»:(f�pi+�cirt8 the hieaNh at tltie i�llviduel� <br /> �,�a�dv,{�}serious anpa�r�rrt ro E►oa�y fcunctions;ar{iii>seria�dystundion oF er►r 6o�,r or�n or part.En�ples cr syymptoma tt�r mmu�yy inaic�te <br /> e preser�of an emcrpency medical c�ditia�indude,but ara not tftniGad ta,d�1�r bteaihiny�.severe chest pair�,canvu�ns or pers�tent severe <br /> 1dQtf111'IS{p8iR8.� <br />