(Use above deductible for separate accumulation..) [All other Covered Charges Per Covered Person Per Covered Family (Use above if Tier 1 deductible can be satisfied independently; Tier 1 accumulates toward Tier 2) Copayment applies after the Cash Deductible is satisfied $1,000 $2,000 $2,500 $5,000 Preventive Care Primary Care Provider Services Visits [when care is provided by the pre-selected PCP] Specialist Visits [and PCP visits if the PCP was not Maternity Care (Pre-natal visits) All Other Practitioner Visits Hospital Confinement Extended Care and Rehabilitation [Complex Imaging Services See Definition [[All other] radiology services NONE N/A See Tier 2 Tier 1 $30 NONE N/A See Tier 2 $300 per day up to $1500 per confinement; up to $3000 per year $300 per day up to $1500 per confinement; up to $3000 per year N/A See Tier 2 N/A See Tier 2 NONE $30 Tier 2 $50 NONE $30 $500 per day up to $3000 per confinement; up to $5000 per year $500 per day up to $3000 per confinement; up to $5000 per year $100 per procedure] $75 per procedure] Laboratory Services NONE $30 per visit Emergency Room Visit Outpatient Surgery $50 $100 $100 $250
provide full-time Skilled Nursing Care by or under the supervision of Nurses; be staffed and equipped to give emergency care; and have written back-up arrangements with a local Hospital for emergency care. We will recognize it if: it carries out its stated purpose under all relevant state and local laws; or it is approved for its stated purpose by the Accreditation Association for Ambulatory Care; or it is approved for its stated purpose by Medicare. We do not recognize a Facility as a Birthing Center if it is part of a Hospital. Board means the Board of Directors of the New Jersey Individual Health Coverage Program, appointed and elected under the laws of . [Brand Name Drug means: a) a Prescription Drug as determined by the Food and Drug Administration; and b) protected by the trademark registration of the pharmaceutical company which produces them.] Calendar Year means each successive 12 month period which starts on January 1 and ends on December 31. Cash Deductible means the amount of Covered Charges that a Covered Person must pay before this Policy pays any benefits for such charges. Cash Deductible does not include Coinsurance, Copayments and Non-Covered Charges. Church Plan has the same meaning given that term under Title I, section 3 of Pub.L.93-406, the “Employee Retirement Income Security Act of 1974” Coinsurance means the percentage of a Covered Charge that must be paid by a Covered Person. Coinsurance does not include Cash Deductibles, Copayments or Non-Covered Charges. [Complex Imaging Services means any of the following services: Computed Tomography (CT), Computed Tomography Angiography (CTA), Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiogram (MRA), Magnetic Resonance Spectroscopy (MRS) Positron Emission Tomography (PET), Nuclear Medicine including Nuclear Cardiology.] Copayment means a specified dollar amount a Covered Person must pay for specified Covered Charges. Note: The Emergency Room Copayment, if applicable, must be paid in addition to the Cash Deductible, any other Copayments, and Coinsurance. Cosmetic Surgery or Procedure means any surgery or procedure which involves physical appearance, but which does not correct or materially improve a physiological function and is not Medically Necessary and Appropriate.