- Lab & X-Ray/Imaging Interpretation - Radiotherapy - Chemotherapy - Homodialysis - Rehab. Therapy Inpatient Hospital – Phys. Visit and Consults. No Charge 80% After Deductible No Charge 50% After Deductible 100% After Deductible 80% After Deductible Outpatient Surgical Facility Services - Operating & Recovery Room $150 80% After Deductible $150 Copay 50% After Deductible 100% Deductible 80% After Deductible - Lab & X-Ray/Imaging - Anesthesia - Drugs, Medications - Hemodialysis - Radiotherapy - Chemotherapy - Supplies (including Durable Medical Equipment used confined) Outpatient Professional Services - Surgeon/Co-Surgeon No Charge 80% Deductible No Charge 50% After Deductible 100% After Deductible 80% After Deductible - Anesthesiologist - Lab & X-Ray/Imaging Interpretation - Radiotherapy - Chemotherapy - Therapy Independent Lab & X-Ray/Imaging Services - Doctor’s Offices No Charge 80% After Deductible No Charge 50% After Deductible 100% After Deductible 80% After Deductible - Dedicated Lab & X-Ray Facility - Hospital Outpatient Department Mammograms No Charge 80% After Deductible No Charge 50% After Deductible $0 Copay per visit 80% After Deductible Women ages 40 and over, annually Outpatient Short Term Rehab. $25 Per Visit No Limit 80% Deductible No Visit Limit $25 Per Visit 90 Visits Combined Maximum. 50% Coinsurance 90 visits Combined Maximum. 100% Deductible 90 Visits Combined Maximum. 80% After Deductible 90 visits Combined Maximum. Other Inpatient Healthcare Facilities* No Charge 80% Deductible No Charge 50% Coinsurance 100% After Deductible 80% After Deductible
provider. If not a true emergency then coinsurance level applied to covered services. provider. If not a true emergency then coinsurance level applied to covered services. provider. If not a true emergency then coinsurance level applied to covered services. - Hospital Emergency Room $100 Copay (Waived if Admitted) Emergency care meeting of CT prudent person’s definition of emergency will be paid at levels regardless of the provider. If not a true emergency then coinsurance level applied to covered services. $100 Copay (Waived if Admitted) Emergency care meeting State of CT prudent person’s definition of emergency will be paid at in-network levels regardless of the provider. If not a true emergency then coinsurance level applied to covered services. 100% After Deductible Emergency care meeting State of CT prudent person’s definition of emergency will be paid at in-network levels regardless of the provider. If not a true emergency then coinsurance level applied to covered services. - Urgent Care Facilities $75 Copay (Waived if Admitted) Emergency care meeting State of CT prudent person’s definition of emergency will be paid at levels regardless of the provider. If not a true emergency then coinsurance level applied to covered services. $75 Copay (Waived if Admitted Emergency care meeting State of CT prudent person’s definition of emergency will be paid at in-network levels regardless of the provider. If not a true emergency then coinsurance level applied to covered services. 100% After Deductible Emergency care meeting of CT prudent person’s definition of emergency will be paid at in-network levels of the provider. If not a true emergency then co-insurance level applied to covered services. - Ambulance No Charge Emergency care meeting of CT prudent person’s definition of emergency will be paid at in-network levels regardless of the provider. If not a true emergency then coinsurance No Charge Emergency care meeting State of CT prudent person’s definition of emergency will be paid at in-network levels regardless of the provider. If not a true emergency then coinsurance 100% After Deductible Emergency care meeting State of CT prudent person’s definition of emergency will be paid at in-network levels of the provider. If not a true emergency then co-insurance