Active Employees & non-Medicare eligible Retirees
| Plan Specifics | You Pay |
|---|---|
| Calendar-year Out-of-Pocket Maximum | $3,400 in-network or $5,100 for combined in- and out-of-network medical services |
| Benefit | You Pay (In-Network) |
| Preventive care, routine physicals, GYN, routine hearing and vision exams | No cost |
| Doctor's Office Visits | $25 per visit |
| Emergency room | $75 per visit, waived if admitted within 24 hours |
| Inpatient hospital care |  $150 per day – days 1-5 $0 per day – after day 5 $750 annual out-of-pocket limit |
| Outpatient surgery | $150 per visit |
| CT scan, MRI's, PET scans, and nuclear cardiac imaging tests | $150 per day for CT scans |
| Lab tests, X-rays, and other diagnostic tests | No cost |
