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Group Name Plan Type 2020 PPO Copay Rochester Regional Health
Group Name Plan Type
2020 PPO CopayRochester Regional Health
Welcome
With Excellus BlueCross BlueShield, you get what you expect from Blue plus a whole lot more such as:
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• Answers to your health questions online
• Local customer service
In this booklet you will find:
• A chart that summarizes this plan’s unique benefits and coverage*
• A glossary of terms to help you understand your coverage and options
We have many valuable benefits and we provide a tremendous amount of choice. Whichever plan you pick, we're ready to meet your health care needs.
Visit us at excellusbcbs.com
*This benefit summary is not a contract or binding agreement;it is a summary of benefits and services.
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2020 PPO Copay
Rochester Regional Health
or visit us at excellusbcbs.com/rrh
Plan Features
Primary Care Physician (PCP) Not Required
Referrals Not Required
Out of network benefits Covered
Student / Dependent Coverage Covered to age 26
Domestic Partner Covered
Coverage Period 01/01/20-12/31/20
20029
Excellus BluePPO$10/$40/$60 Domestic, $25/$70/$110 Non Domestic
Benefit Time Period: 01/01/2020 - 12/31/2020
ROCHESTER REGIONAL HEALTH SYSTEM
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General Information
Cost Sharing Expenses
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Deductible - Single $0 $0 $1,800
Deductible - Family $0 $0 $5,400Each individual does not exceed the single deductible.
Coinsurance 0% 0% 40%
Annual Out of Pocket Maximum - Single $5,000 $5,000 $9,000
Out-of-pocket maximums accumulate the coinsurance amount and include the deductible, including carry over deductible if applicable, and copayment.
Annual Out of Pocket Maximum - Family $10,000 $10,000 $18,000
Each individual does not exceed the single out of pocket maximum. Out-of-pocket maximums accumulate the coinsurance amount and include the deductible, including carry over deductible if applicable, and copayment. Once family OOP maximum has been met by any number of individuals, OOP maximum is met for all. One OOPM for both Domestic and In-Network combined.
Office Visit Cost Shares
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Cost Share - Primary Care $30 Copayment $95 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 Copay for In-Network
Cost Share - Specialist $50 Copayment $155 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $50 Copay for In-Network
Plan Limits
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Plan/Calendar Year Calendar Year Benefits
Diabetic Preauthorization and Step Therapy
No
Who is Covered
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Domestic Partner Coverage Yes
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Inpatient Facility
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Inpatient Hospital Services $750 Copayment $2,000 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $750 Copay for In-Network.
Mental Health Care $750 Copayment $2,000 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $750 Copay for In-Network.
Substance Use Detoxification $750 Copayment $2,000 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $750 Copay for In-Network.
Skilled Nursing Facility $750 Copayment $2,000 Copayment40% CoinsuranceSubject to Deductible
120 Days Per Plan Year360 Days Lifetime Max. Pediatric (up to and including age 18): $750 Copay for In-Network. Limits are combined Domestic, INN and OON.
Physical Rehabilitation Covered in Full $2,000 Copayment40% CoinsuranceSubject to Deductible
60 Days per yearPediatric (up to and including age 18): Covered in full for In-network. Limits are combined Domestic, INN and OON.
Maternity Care $750 Copayment $2,000 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $750 Copay for In-Network.
Inpatient Professional Services
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Inpatient Hospital SurgeryPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in full for In-network
AnesthesiaPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
Covered in Full up to schedule of allowance
Includes anesthesia rendered for Inpatient, Outpatient, Office Visit, and Maternity services. Anesthesia does not require a preauth or referral. Pediatric (up to and including age 18): Covered in full for In-network
Outpatient Facility Services
Outpatient Facility Services
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
SurgiCenters and Freestanding Ambulatory Centers Surgical Care
$250 Copayment $2,000 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $250 Copay for In-Network.
Diagnostic X-ray $50 Copayment $155 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $50 Copay for In-Network. Advanced Imaging Services includes PET scans, MRI, nuclear medicine, and CAT scans.
Diagnostic Laboratory and Pathology Covered in Full $155 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in full for In-Network.
Radiation Therapy Covered in Full $155 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Chemotherapy Covered in Full $155 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Infusion TherapyInclusive of Primary Service
Inclusive of Primary Service
Inclusive of Primary Service
Is inclusive in the Home Care benefit and not covered as a separate benefit.
Inpatient Services
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Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Dialysis Covered in Full $155 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Mental Health Care $30 Copayment $95 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 Copay for In-Network. Includes Partial Hospitalization
Substance Use Care $30 Copayment $95 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 Copay for In-Network. Includes Partial Hospitalization
Home and Hospice Care
Home Care
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Home Care Covered in Full $155 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in full for In-network
Home Infusion Therapy Covered in Full $155 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in full for In-network
Hospice Care
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Hospice Care Inpatient $750 Copayment $2,000 Copayment40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $750 Copay for In-Network
Outpatient and Office Professional Services
Professional Services
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Office SurgeryPCP -$30 CopaymentSpecialist -$50 Copayment
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network.
Diagnostic X-rayPCP -$30 CopaymentSpecialist -$50 Copayment
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network.
Diagnostic Laboratory and PathologyPCP -$30 CopaymentSpecialist -$50 Copayment
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network.
Radiation TherapyPCP -$30 CopaymentSpecialist -$50 Copayment
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network. 1 copay per visit.
ChemotherapyPCP -$30 CopaymentSpecialist -$50 Copayment
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network. 1 copay per visit.
Infusion TherapyPCP/Specialist - Inclusive of Primary Service
PCP/Specialist - Inclusive of Primary Service
Inclusive of Primary Service
Is inclusive in the Home Care benefit and not covered as a separate benefit.
DialysisPCP -$30 CopaymentSpecialist -$50 Copayment
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network. 1 copay per visit.
Mental Health CarePCP/Specialist - $30 Copayment
PCP/Specialist - $95 Copayment
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 PCP/Specialist Copay for In-Network.
Maternity CarePCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in full for In-network
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Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
TeleMedicine ProgramPCP/Specialist - Not Covered
PCP/Specialist - Not Covered
Not Covered Not Covered
Chiropractic CarePCP/Specialist - Not Available
PCP/Specialist - $30 Copayment
40% CoinsuranceSubject to Deductible
30 visits per year
Allergy TestingPCP -$30 CopaymentSpecialist -$50 Copayment
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network. Allergy Testing includes injections and scratch and prick tests.
Allergy Treatment Including SerumPCP/Specialist - Covered in Full
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network. Includes desensitization treatments (injections & serums).
Hearing Evaluations RoutinePCP/Specialist - Not Available
PCP - $30 CopaymentSpecialist - $50 Copayment
40% CoinsuranceSubject to Deductible
1 Exam every 2 yearsPediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network.
Rehab and Habilitation
Outpatient Facility
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Physical Rehabilitation $50 Copayment $155 Copayment40% CoinsuranceSubject to Deductible
30 Visits Per Plan YearPediatric (up to and including age 18): $50 Copay for In-Network. Includes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy.
Occupational Rehabilitation $50 Copayment $155 Copayment40% CoinsuranceSubject to Deductible
30 Visits per yearPediatric (up to and including age 18): $50 Copay for In-Network. Includes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy.
Speech Rehabilitation $50 Copayment $155 Copayment40% CoinsuranceSubject to Deductible
30 Visits per yearPediatric (up to and including age 18): $50 Copay for In-Network. Includes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy.
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Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Physical RehabilitationPCP -$30 CopaymentSpecialist -$50 Copayment
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
30 Visits per yearPediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network. Includes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy.
Occupational RehabilitationPCP -$30 CopaymentSpecialist -$50 Copayment
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
30 Visits per yearPediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network. Includes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy.
Speech RehabilitationPCP -$30 CopaymentSpecialist -$50 Copayment
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
30 Visits per yearPediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network. Includes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy.
Preventive Services
Preventive Professional Services Meeting Federal Guidelines*
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Adult Physical ExaminationPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
1 Exam Per Plan YearPediatric (up to and including age 18): Covered in Full for In-Network.
Adult ImmunizationsPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Well Child Visits and ImmunizationsPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Routine GYN VisitPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Pre/Post-Natal CarePCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Mammography Screening ProfessionalPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
NYS Mammography Screening Mandates Applies - One Annual Mammogram for ages 35-39. Pediatric (up to and including age 18): Covered in Full for In-Network.
Colonoscopy Screening ProfessionalPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Bone Density Screening ProfessionalPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Preventive Facility Services Meeting Federal Guidelines*
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Cervical Cytology Preventative Covered in Full Covered in Full40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Mammography Screening Facility Covered in Full Covered in Full40% CoinsuranceSubject to Deductible
NYS Mammography Screening Mandates Applies - One Annual Mammogram for ages 35-39. Pediatric (up to and including age 18): Covered in Full for In-Network
Colonoscopy Screening Facility Covered in Full Covered in Full40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Outpatient Professional Services
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Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Bone Density Screening Facility Covered in Full Covered in Full40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Preventive services in addition to those required under Federal Guidelines - Professional
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Prostate Cancer ScreeningPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network. NYS Prostate Cancer Testing Mandate applies.
Mammography Screening ProfessionalPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
NYS Mammography Screening Mandates Applies - One Annual Mammogram for ages 35-39. Pediatric (up to and including age 18): Covered in Full for In-Network
Colonoscopy Screening ProfessionalPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Bone Density Screening ProfessionalPCP/Specialist - Covered in Full
PCP/Specialist - Covered in Full
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network. Not performed as part of office visit
Preventive services in addition to those required under Federal Guidelines - Facility
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Mammography Screening Facility Covered in Full Covered in Full40% CoinsuranceSubject to Deductible
NYS Mammography Screening Mandates Applies - One Annual Mammogram for ages 35-39. Pediatric (up to and including age 18): Covered in Full for In-Network
Colonoscopy Screening Facility Covered in Full Covered in Full40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Bone Density Screening Facility Covered in Full Covered in Full40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): Covered in Full for In-Network.
Other Benefits
Additional Benefits
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Treatment of Diabetes Insulin and Supplies
PCP -$30 CopaymentSpecialist -$50 Copayment
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network. Limited to a 30 day supply for retail pharmacy or a 90 day supply for mail order pharmacy.
Diabetic EquipmentPCP -$30 CopaymentSpecialist -$50 Copayment
PCP - $95 CopaymentSpecialist - $155 Copayment
40% CoinsuranceSubject to Deductible
Pediatric (up to and including age 18): $30 PCP/$50 Specialist Copay for In-Network.
Durable Medical Equipment (DME)PCP/Specialist - Not Available
PCP/Specialist - 20% Coinsurance
40% CoinsuranceSubject to Deductible
Medical SuppliesPCP/Specialist - Not Available
PCP/Specialist - 20% Coinsurance
40% CoinsuranceSubject to Deductible
AcupuncturePCP/Specialist - 50% Coinsurance
50% CoinsuranceSubject to Deductible
10 Visits per yearLimits combined Domestic, INN and OON.
Private Duty NursingPCP/Specialist - Not Covered
PCP/Specialist - Not Covered
Not Covered Not Covered
PCP/Specialist - Not Available
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Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Facility Emergency Room Visit $250 Copayment $500 Copayment $500 Copayment
Pediatric (up to and including age 18): $250 Copay for In-Network and Out-of-Network. Prior Authorization may not apply to any emergency care services. Emergency services are covered worldwide if provided by a hospital facility.
Transportation
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Prehospital Emergency and Transportation - Ground or Water
Not Available $155 Copayment $155 Copayment
Urgent Care
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Urgent Care Center Facility Visit $30 Copayment $95 Copayment40% CoinsuranceSubject to Deductible
Pediatric up to and including age 18: $30 Copay for In-Network
Ancillary Benefits
Vision
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Adult Eye Exams - Routine Covered in Full Covered in Full40% CoinsuranceSubject to Deductible
1 Exam per yearLimits are combined INN and OON. One pair of corrective lenses after cataract surgery covered in full.
Adult Eyewear - Routine Covered Covered40% CoinsuranceSubject to Deductible
$60 Allowance per yearIncludes Frames/Lenses or Contact Lenses
Pediatric Eye Exams - Routine Covered in Full Covered in Full40% CoinsuranceSubject to Deductible
1 Exam Per Plan YearLimits are combined INN and OON. Pediatric (up to and including age 18): Covered in Full for In-Network. One pair of corrective lenses after cataract surgery covered in full.
Pediatric Eyewear - Routine Covered Covered40% CoinsuranceSubject to Deductible
$60 Allowance per plan yearIncludes Frames/Lenses or Contact Lenses
Rx Benefits
Rx Plan
Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Rx Plan$10/$40/$60 Domestic, $25/$70/$110 Non Domestic
Emergency Services
ER Facility
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Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information
Days Supply Per Retail Order 90 90
Days Supply Per Mail Order Not Available 90
Copays Per Mail Order Supply Not Available 3
This document is not a contract. It is only intended to highlight the coverage of this program. Benefits are determined bythe terms of the contract. Any inconsistencies between this document and the contract shall be resolved in favor of thecontract in effect at the time services are rendered. All benefits are subject to medical necessity. All day and visit limits arecombined limits for both in and out of network benefits.
* For non-grandfathered groups, Preventive Services coverage required by the Patient Protection and Affordable Care Act are notquoted herein. Please refer to the United States Preventive Services Task Force (USPSTF) list of items and services rated "A" or"B", the guidelines supported by the Health Resources and Services Administration (HRSA) and the list of immunizationsrecommended by the Advisory Committee on Immunization Practices (ACIP) for a complete list of services that are coveredpursuant to the Patient Protection and Affordable Care Act requirements.
Rx Benefits
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© 2000–2019 Blue Cross and Blue Shield Association — All Rights Reserved. The Blue365 program is brought to you by the Blue Cross and Blue Shield Association and Excellus BlueCross BlueShield. The Blue Cross and Blue Shield Association is an association of independent, locally operated Blue Cross and/or Blue Shield Companies. Blue365 offers access to savings on health and wellness products and services and other interesting items that Members may purchase from independent vendors, which are not covered benefits under your policies with Excellus BlueCross BlueShield its contracts with Medicare, or any other applicable federal healthcare program. These products and services will be offered to you through the entire benefit year. During the year, the independent vendors may offer additional discounts on these products and services. To find out what is covered under your policies, contact Excellus BlueCross BlueShield. The products and services described on the Site are neither offered nor guaranteed under Excellus BlueCross BlueShield's contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding your health insurance products and services may be subject to Excellus BlueCross BlueShield's grievance process. BCBSA may receive payments from vendors providing products and services on or accessible through the Site. Neither BCBSA nor Excellus BlueCross BlueShield recommends, endorses, warrants, or guarantees any specific vendor, product or service available under or through the Blue365 Program or Site.
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B-2850
Primary Care Physician (PCP)—A doctor who serves as your health care manager and coordinates virtually all of the health care services you routinely receive. Some plans do not require you to choose a PCP.
Referral—Instructions provided by a PCP for specialty care. Most plans do not require referrals.
In-network coverage—The coverage available when you receive services from a provider who participates in your health plan.
Out-of-network coverage—The coverage available when you receive services from a provider who does not participate in your health plan. Some plans may not include out-of-network coverage.
Out-of-area—Describes when you receive services while outside the geographic service area of your health plan. Your plan benefits may differ if you live or work beyond the geographic service area.
Copay—A dollar amount due at the time you receive certain services. A typical example would be an office visit copay due when visiting your physician’s office for treatment.
Allowed Amount—The maximum amount your health plan will pay for a specific service. In-network providers agree to accept the allowed amount as payment in full.
Coinsurance—A cost-sharing method that requires you pay a portion of the allowed amount for certain medical services.
Deductible—A set dollar amount you pay for covered services you receive before your insurer will make a payment.
Out-of-pocket maximum—The maximum amount of deductible and coinsurance payments that you will pay for health services each calendar year.
To help you better understand our plans and your coverage, here are a few definitions* for frequently used health care terms.
Some definitions may vary slightly by plan. In case of a conflict between your legal plan documents and this information, the plan documents will govern.
Health plan terms
*
Inside Back Cover
