Active employees & non–Medicare-eligible retirees
| Plan Specifics | You Pay |
|---|---|
| Calendar-year out-of-pocket max | $3,400 calendar-year out-of-pocket maximum (excludes prescription drug cost-sharing) |
| Benefit | You Pay (In-Network) |
|---|---|
| Medicare-covered preventive care and screening tests | Nothing |
| Doctor's office visits | $15 per primary care provider (PCP) visit $35 per specialty care visit |
| Emergency room | $75 per visit, waived if admitted within 24 hours |
| Inpatient hospital care | $150 per day—days 1-5 |
| Outpatient surgery | $150 per visit |
| CT scan, MRIs, PET scans, and nuclear cardiac imaging tests | $150 per day1 |
| Lab tests, X-rays, and other diagnostic tests | $10 per day1 |
- Imaging costs are waived when performed on the same day as an emergency visit or outpatient day surgery.
