| Plan Specifics | You Pay (In-Network Costs) | |
|---|---|---|
| Plan-year deductible | $0 | |
| Plan-year out-of-pocket maximum | $3,400 in-network or $5,100 for the combined in- and out-of-network medical services—this is the maximum out-of-pocket amount you pay each year for Medicare-covered services | |
| Benefit | You Pay | |
| Preventive care, routine physicals, GYN, well child, routine hearing and vision exams, family planning | Nothing | |
| Office visits (sick care/ non-preventive) | $25 per visit | |
| Emergency room | $65 per visit, waived if admitted within 24 hours | |
| Inpatient hospital care |
|
|
| Outpatient surgery | $100 per visit | |
| CT scans, MRIs, and other imaging tests |
|
|
$150 per day for 1–5 days
