 |
 |
 |
 |
 |
 |
 |
 |
|
|
|
|
|
|
 |
|
|
 |
|
|
 |
 |
|
|
|
 |
Summary Plan Description (SPD)
Summary of Plan Benefits When Using a Non-Participating Provider
Deductibles
Calendar Year Deductibles
- Member or Dependent Deductible- $200
- Family Deductible - $600 for all eligible family members
- Hospital Deductible Per Confinement - $200
Overall Lifetime Maximum
- Each Employee or Eligible Dependent - $1,000,000
Copayments
- The Plan will pay 80% of the first $12,500 of family covered charges after the deductible, every calendar year, and 100% of covered charges over $12,500 per family every calendar year.
Note: Covered Charges are based on a limited schedule of benefits. The charge made by a non-participating provider may be more than the amount allowed by the schedule of benefits. You are responsible for the difference between these charges in addition to your copayment of 20%.