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Coverage Period:. 0110112017-1-2/31,12017 <br />City -of Lakewood : Plan I <br />Summary of Benefits and Coverage: What This Plan Covers & What it Cosh- Comage for: Si-ingle G-r Fam, fly I Plan Type: PPO <br />dollar amounts. (f6r e,.Q.,mple. S-,,*.Tj v yA <br />Copa=ents are fixed nu �pay for w-vered heafth care., usualil ).he.rg you receive the service_ <br />CoinsuraMiayourshareof the rmsts-of a covereedser0ce, caloutaWdas ape-mentof lhe affowed am- for !he semi.ce- Forexam-.,ple, ifith-eplan."s <br />allowed aounmfor an overnight hospital stay is $1,000, your payment. of 20% woWd be *$2-00:. This mail charge If youhavenl met your <br />deduefible, <br />The amourt ft plan pays for- w�rereed serjices is based on the allowed anwunt If an out-oketwork wavider charges more than the alla -wed <br />amount you ff my have to pay the di ftlmnce.- For exAmple, ff an out okebwo* hospital .urges $1,500. for an overnigYt stay and the allwmd arnoun.t is <br />$1,000., you may have to pad. ire $500 Mmerence. (Thin 'G called balance billing <br />This tan mail encourage. you to use Network oravidm bycha4ing you tbww- deductibles, copayments and cainsurance amunts- <br />City of Lakewood: Plan I Covera-ge 12,13-112017 <br />Summary of Benefits and Coverage: Mat This Plan -Covers & What it Costs Coveraqe;for.- Singleor Farmy [ Plan Typet. PPO <br />Genen-c wpay - retail Rx. <br />I Does Not A pply. <br />-oven up to a 34-d-a supply� <br />Genenc copay - home delivery Rx <br />.12-50 <br />Does Not Apply <br />Covers up. tz a 90-day sup Ov,. <br />Brand Nwme copay - retail Rx <br />-108;inq,.IeSa,,xrreIno <br />Does W.Apply <br />----------sup <br />Oovers uplo a 34-day ply <br />-generiC. manufacbured); <br />15 PJW&Source <br />................. <br />.... <br />e. $25 8, n .............. <br />Brand Namecopay -horne. livery Sj gle Scurce -.,(no <br />. Does N&Appl� <br />Govers q. to a -dad supply- <br />13 <br />1R. x <br />ger eric. ff w. uAwtured)- <br />$37.50 MA-Sourca <br />- ----------------- .............. -------­­ <br />... ..... .. .. . .. .. <br />fee (e.g., a mbulatiory surgerl <br />N ch, rg-- after deductible I 3G,%cain.suranice <br />Center) <br />..... . ..... .............. __ .................. <br />......... <br />Physiciantsurgeon Rees en*` f­)'_"",I* <br />No- charge- after 3G% rcciinsurance <br />one <br />1"', <br />Evnergency mamstemices. <br />No. charge -a Per educfib-,le <br />ri�n�' <br />Erriergenq m,-diatranspottation <br />i No charg.e. after deducible 301% c6insurance <br />—none- <br />Urgent. care <br />.. . .... . <br />ance after deduct <br />'ble 30% insur <br />Facifiry-fee (e.-., hospital rooms <br />Ma -harge. afteer dedurAble I Wfa- coinsurance <br />--none— <br />is:::. . .cam-.::. ..... ... �.;­ <br />Ph�.ysicianf s wgeon fee ;;,inpatrenQ No charge. after &-ductib-le 3GIX. co-insuranc <br />.................. ...... <br />MI <br />