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�Wiin 2 P6AIAC) �3hAiirf4,C)IN SII l ll lull <br /> Inilt Ovoraqc k1% ,iloh ni I n III 1::::IIILIIr Pylae: HIPH <br /> Co-payments are fixed dollar amounts(for example,$15)you pay for covered health care,usually when you receive the service. <br /> Co-insurance is ycurshare of the costs of a covered service,calculated as a percent of the allowed amount for the service.For example,if the plan's <br /> allowed amount for an overnight hospital stay is$1,000,Vpur,co-insurance payment of 1'0%would be 5100. This may change if you haven't met your <br /> deductible. <br /> The amount the plan pays for covered services is based on the,allowed amount. IIf an out-of-rietworkprovides charges more than Oe allowed <br /> amount,you may have to pay the difference.For example,if an out-of-network hospital charges$1,5100 for an overnight stay and the allowed amount is <br /> $1,000,you may have to pay the$500 difference.(This is callqd,balance billing.) <br /> This plan may encourage you to use N,eltwork,RE2yliders by charging you lower deductibles,co-payments and co-insurance amounts <br /> Primary care visit totreat an injury or illness 10%co-insurance 36%co-Insurance --r1ore, <br /> If you visit a health care provider's Specialist visit 10%co-irsurance 3C%co-Insurance <br /> office or cl i n i c Other practitioner office visit 104 co-insurance 30%co-Insurance -----none------- <br /> (Chiropractic) <br /> Other practitioner office visit Not Covered Excluded Service <br /> (Acupuncture) <br /> Preventive carel screeirini No charge Not Covered --nore, <br /> immunization <br /> Diagnostic test(x-riaylI 10%co-irsurance 3t%co-Insurance <br /> If you have a test Diagnostic test(blood worlk) IM co Insurance 30%co-Insurance -----none <br /> Imaging(CUETscars,MRlis) 10%co-irsurance 36%co-Insurance <br /> Oenerii-retail Mx S10 Does n;ai apply Cooars up,to,a 34-day <br /> Generic oopae-home delh-IVIRx 525 Does and apply Cow-rs upta a 90-day <br /> Preferred Brand oopay-retat/RX 820 Does nor ap�p�li Gn,,,ar,up to a34-day <br /> Ifyou need drugs to treat your illness Preferred Fiand coiday-honne dervarylRX 650 Does not apply covar5 up to a 9,3-jay <br /> or condition provided by Express <br /> Scripts Non-ideferred bramdmipay-retaiVRX S35 Does nal apply covar5 up to ado-jay <br /> Non-ideferred brand ropey-home dell S97.50 Does nor appy covar5 up to a 9,3-jay <br /> 'unrriq <br /> If you have outpatient su irgery Facility fee(e.g.,ambulaticly surgery center) IM co Insurance 301%co-Insurance -----none------- <br /> Physician/surgeon fees(Outpatient) 104 co-insurance 301%co-Insurance --nore, <br /> 36 <br />