Summary Plan Description

Medical Benefits

Summary

Most covered expenses received from a network provider are paid at 90 percent by the plan and at 10 percent by the patient, after the patient's $200 annual deductible is satisfied. When a patient's coinsurance reaches the $2,300 or $4,600 annual coinsurance maximums, the patient pays no coinsurance for the remainder of that calendar year for covered expenses incurred from a network provider. Medicare-eligible retiree expenses are processed at the network coinsurance rate. Most covered expenses received from a non-network provider are paid at 80 percent of the maximum allowable fee with 20 percent coinsurance and the patient's coinsurance expenses for these services do not apply toward the $2,300 or $4,600 annual coinsurance maximums or the $4,000 or $8,000 out-of-pocket maximums. Some benefits are always paid at 50 percent with 50 percent coinsurance and the patient's coinsurance expenses for these services do not apply toward the $2,300 or $4,600 annual coinsurance maximums or the $4,000 or $8,000 out-of-pocket maximums. The payment percentage for each benefit is indicated next to the benefit title. If a covered service or supply qualifies under more than one of the benefits described in this section, the plan reserves the right to determine under which benefit payment is made.

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