Flex Copay Series Facility/Ancillary Care

Pick network cost-sharing for facility and ancillary care.

Facility/Ancillary	F1	F2	F3	F4	F5¹
Hospital Services²
(Unlimited inpatient days)	$0	$100/day Max 5 days ($500)	$150/day Max 5 days ($750)	$250/day Max 5 days ($1,250)	$400/day Max 5 days ($2,000)
Outpatient Surgery²
	$0	$50	$75	$125	$200
Skilled Nursing Facility²
(120 days per cal. year³) (copay not waived if admitted from inpatient hospital stay)	$0	$50/day Max 5 days ($250)	$75/day Max 5 days ($375)	$125/day Max 5 days ($625)	$200/day Max 5 days ($1,000)
Emergency Room
(Copay not waived if admitted)	$100	$100	$100	$100	$125
Outpatient Private Duty Nursing²
(360 hours per cal. year³)	90%	90%	85%	85%	80%
Prosthetics and Durable Medical Equipment²
	70%	70%	50%	50%	50%

Coinsurance is based upon Plan allowance and reflects amount paid by the Plan.

¹F5 can only be paired with C3 or C4.

²Pre-Authorization required for certain services.

³For Personal Choice, combined in/out-of-network maximum.