• Diagnostic and treatment services provided in the office

PPO: 15%* of our allowance; $20 per office visit

Non-PPO: 30%* of our allowance

• Inpatient

PPO: $200 per admission - Preferred

PPO: $300 per admission - Member

Non-PPO: $300 per admission

• Outpatient

PPO: 15%* of our allowance - Preferred

Non-PPO: 30%* of our allowance - Member

Non-PPO: 30%* of our allowance (no deductible for surgery)

• Accidental injury

PPO: Nothing for outpatient hospital and physician services within 72 hours; regular benefits thereafter

Non-PPO: Any difference between our payment and the billed amount within 72 hours; regular benefits thereafter

• Medical emergency (Outpatient Physician services, hospital services and supplies)

Preferred: 15%* of our allowance

Note: If you receive services in a Preferred physician's office, you pay a $20 copayment (No deductible) for the office visit, and 15%* of our allowance for all other services (deductible applies).

Participating/Member: 30%* of our allowance

Non-Participating/Non-Member: 30%* of our allowance, plus any difference between our allowance and the billed amount.

Note: For professional care provided in an emergency room by a Non-participating emergency room physician, your responsibility is limited to 100% of the billed amount up to a maximum of $350 per visit (No deductible).

Note: These benefit levels do not apply if you receive care in connection with, and within 72 hours after, an accidental injury.

• Medical emergency (Ambulance transport services)

Preferred: $100 copayment per day for ground ambulance transport services (No deductible)

Participating/Member or Non-participating/Non-member: $100 copayment per day for ground transport services (No deductible)

Note: If you receive medically necessary air or sea ambulance transport services, you pay a copayment of $150 per day

Note: These benefit levels do not apply if you receive care in connection with, and within 72 hours after, an accidental injury.

In-Network (PPO): Regular cost-sharing, such as $20 office visit copayment (prior approval required); $200 per inpatient admission (No deductible)

Out-of-Network (Non-PPO): Benefits are limited

Retail Pharmacy Program:

Preferred Retail Pharmacies (up to a 90 day supply):

• Level I (generic drug): 20% of our allowance
• Level II & II (brand-name drug): 30% of our allowance

Non-preferred Retail Pharmacies: 45% of our allowance (Average wholesale price) plus any difference between our allowance and the billed amount.

Note: If you use a Non-preferred retail pharmacy, you must pay the full cost of the drug or supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed.

Mail Service Prescription Drug Program:

Generic: $10 copayment per generic prescription filled (and/or refill ordered)

Note: The $10 copayment amount is waived for the first 4 generic prescriptions filled (and/or refills ordered) per calendar year.

Brand-name: $65 for first 30 brand-name prescriptions filled (and/or refills ordered) per calendar year; $50 per brand-name prescription/refill thereafter

Note: If there is no generic equivalent available, you must still pay the brand-name copayment when you receive a brand-name drug

Note: If the cost of your prescription is less than your copayment, you pay only the cost of your prescription. The Mail Service Prescription Drug Program will charge you the lesser of the prescription cost or the copayment when you place your order.

Scheduled allowances for diagnostic and preventive services, fillings, and extractions; regular benefits for dental services required due to accidental injury and covered oral and maxillofacial surgery

Protection against catastrophic costs

(your catastrophic protection out-of-pocket maximum)