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City of Lakewood : Plan 1 Coverage lleiric>d� 0114,11/2(H? 'MU20 H <br /> Summary oflBenafha and Coverage: What This Plan Covers&What it Costs Coverage for: Smigle or Family 1 Plan Type,:: FIPO <br /> CoRayments are fixed drillar arriounts(for example,S15)you pay for covered heafth rare,usually when Tiu recevve the Service. <br /> Coinsurance us your share of the costes of a covered service,.aHculatecl as a percent of tie a I I oym d am ou for the service.Far example,ifthe plasms <br /> allowed arnountfor anovernight ha5pqall stay is$1,000,your coinsurance payiiientaf2O'%,v%,oupdlbe$20fl. This inaychange Iffyou haven't inetyour <br /> deductIble, <br /> The amount the plan pays for crivered services is based on the aillowed amount. fain out-of-network prowider charges miore than the allowed <br /> amount you may have to pay the difference.For example,if an out'-of-network.:hospital charges$1,500 far ain overnight stay and the alllowedamount is <br /> $1,000,you may have to pay the$500 diTerence.(This is cafled(balance bill ing'f <br /> This 1plain may encourage you to use Network orovideirs Iby charging you lower cleduefibles.copayments and coinsurancearriounts. <br /> I IT I I <br /> Primary care visit to treat an injury or No charge after deductible 30%voinsurance ----noire------- <br /> Ifyou visit a heallth care ill;ess <br /> providers office or ofinfo Speciadst visit No charge after deductible 30%coinsurance ----noire------- <br /> Other practitioner office visit No charge after deductible 30%coinsurance -------nene------- <br /> (G.lhiropracfiq) <br /> Other practitioner office visit Not Covered Exciuded Serviop <br /> (,Acupuncture'� <br /> Preventive care/5creeningP No charge Not Covered ----none------- <br /> in-rinuinizaRm <br /> Diagnusfic test(x-rayy IMo charge after deductible 30%coinsurance -------none------- <br /> If you Ihave a test diagnostic.test(bloodwork.) No charge after deductible 30%coinsurance ----none------- <br /> maging$CTAPET scars,MRls) No charge after deductible 30%coinsurance ----noire------- <br /> City of Lakewood Plan 1 Covera!ije l::1ei iocL 0,1/01(201,.....12Q 1/2017 <br /> Summary of Beneffis and Coverage: What This Plan Covers&What it Costs Coverage for: Single or Family I Plan Type: PFO <br /> ou m. aq Op FM ji litillillipill wriiiiiiiii iiiiiiiiiirilliriilli!ROM11111111 1111i <br /> G-nefir ccipay-retail!Rx $5 Does Not Apply Govers,up to a 34-day suppy. <br /> Generic ccipay-home delivery Rx $12.50 W Does Not Apply Govers,up to a 53daysuppVy. <br /> If you ineed drugs to treat Biraind Name copy-retail!Rx $10 Single Source,no Does Not Apply Gowers up to a 34-day suppVy. <br /> your lillness or condition generic manufactured), <br /> Mare information about $'15 Multi-Scurce <br /> prescription drug[ Brand 1`4anre copay-home dedwry $25 Single Source(ric, Does Not Apply Covers up to a d3 days supply. <br /> coverage is avail,able at PRx generic manufactured) <br /> MedMutuai.conVSBC $37.50 Mufti-Source <br /> If you have outpatient Facility fee(e.g.,ambulatory surgery No charge after deductible 30%coinsuraine noire------- <br /> surgery center] <br /> Physicianfsurgeon fees(Outp@llent) No charge after deductilicle 30%coinsurance noing------- <br /> Emergency room services No charge after deductible noire- --- <br /> If <br /> oing------- <br /> If you need immediate Emergency nipdir4transportation No charge after c1pductilicle 30%coinsuraince none------- <br /> medical attention Urgent care No charge after deductible 30%coinsuraine noine------- <br /> If you have a hos;pRall stay, Facility fee(-.g.,hospital room) No charge after deductible 30%coin5urainre noine------- <br /> PhysirianP surgeon fee)iirvpatjent) No charge after deductible 30%ccmuraime none------- <br /> 31 <br />