|
Benefit:
|
You
pay at PPO/Network Provider:
|
You
pay at
Non-PPO Provider:
|
|
Services with coinsurance
(excluding mental health and substance abuse care)
|
- Nothing after
your coinsurance expenses total $4000 for PPO providers/facilities
|
- Nothing after
your coinsurance expenses total $6000 for Non-PPO providers/facilities.
When you use a combination of PPO and Non-PPO providers,
your out-of-pocket expense will not exceed $6000
|
|
Mental health and
substance abuse benefits
|
- Nothing after
your coinsurance expenses total $3000 for In-Network mental
health and substance abuse providers/facilities
|
- Nothing after
your coinsurance expenses total $8000 for Out-of-Network
mental health ad substance abuse inpatient hospital treatment
(after 50 days you pay all charges)
|
