Pick the Network coinsurance level for facility and ancillary services.
| Facility/Ancillary | N1 | N2 |
|---|---|---|
| Coinsurance | 80% | 70% |
| Out-of-Pocket Maximum2 Individual/Family |
$3,000/$9,000 |
$5,000/$15,000 |
| DEDUCTIBLE AND COINSURANCE APPLY TO THE FOLLOWING SERVICES: | ||
| Hospital Services** (Unlimited inpatient days) | 80% | 70% |
| Outpatient Surgery** | 80% | 70% |
| Skilled Nursing Facility** (120 days per cal. year*) (Not waived if admitted from inpatient hospital stay) |
80% | 70% |
| Emergency Room (Not waived if admitted) | 80% | 70% |
| Outpatient Private Duty Nursing** (360 hours per cal. year*) | 80% | 70% |
| Prosthetics and Durable Medical Equipment** | 50% | 50% |
| Lab/Pathology1 | 80% | 70% |
| X-Ray/Radiology/Diagnostics1 Routine Radiology MRI/MRA, CT Scans, PET Scans** |
80% 80% |
70% 70% |
Coinsurance is based upon Plan allowance and reflects the amount paid by the Plan.
* For Personal Choice, combined in/out-of-network maximum.
** Pre-authorization required.
1 For Personal Choice options, deductible and coinsurance apply to these services. Copayment amounts apply to HMO and Keystone Direct POS options.
2 Only member coinsurance is applied to the out-of-pocket maximum.