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SECTION A. Summary of Benefits for Active Members
This Summary is part of your Benefit Handbook. It states the Cost Sharing amounts that you must pay for
Covered Benefits and some important limitations on your coverage. It also identifies any supplemental medical
benefits included in your Plan.
For complete information on Covered Benefits, including limitations on your coverage, you must refer to
Section C of the Benefit Handbook, and if applicable, Section D for Supplemental Benefits and Section
Q for Prescription Drug Coverage. For information on how the PPO Plan works, please see Section B
of the Benefit Handbook.
Please note when using Non-Participating Providers, you are financially responsible for the difference
between the Usual, Customary and Reasonable Charge (UCR) amount allowed by the Plan and the amount
charged by the Provider. Please refer to Section B.3.g for additional information about Usual, Customary
and Reasonable Charges.
General Cost Sharing Features In-Network Out-of-Network
Coinsurance See Covered Benefits below See Covered Benefits below
Copayment See Covered Benefits below See Covered Benefits below
Deductible - (combined In-Network and Out-of-
Network)
$500 / $1,000/ $2500 per Member per calendar year
$1000 / $2,000 / $5000 per family per calendar year
Non-Biologically Based Mental Illness Deductible
- (combined In-Network and Out-of-Network) $150
Deductible Rollover Included
Out-of-Pocket Maximum - (combined In-Network
and Out-of-Network and excludes Copayments, and
Deductible and Coinsurance amounts for Non-
Biologically Based Mental Illness services)
$1500 / $3,000 / $ 3500per Member per calendar year
$3000 /$6,000 / $7000 per Family per calendar year
Lifetime Benefit Maximum (combined In-Network
and Out-of-Network and excludes Deductible and
Coinsurance amounts for Non-Biologically Based
Mental Illness services)
$3,000,000 per Member per lifetime
Penalty Payment None $500