Highlights:
| Benefit | Coverage |
|---|---|
| Out-of-pocket maximum (Excludes deductible) |
$15,000 individual, $25,000 family combined in and out of network |
| Annual benefit maximum | $500,000 per individual combined in and out of network |
| Annual outpatient services maximum (Excludes all office visits) |
$1,500 per individual combined in and out of network |
| Annual inpatient services maximum (Includes physicians' and surgeons' services) |
$7,500 per individual combined in and out of network |
| In Network | |
| Physicians' office visits | 100% after $25 copay |
| Diagnostic X-rays, lab tests and procedures (non-routine) | 80% (subject to annual outpatient services maximum) |
| Hospital services | 80% after $500 copay per admission |
| Out of Network | |
| Annual deductible | $200 per individual |
| Physicians' office visits | 60% after deductible |
| Diagnostic X-rays, lab test and procedures (non-routine) | 80% after deductible (subject to annual outpatient services maximum) |
| Hospital services | Not covered |
For details, download this benefits summary:
| Publications | View |
|---|---|
| 2007-08 Coventry Episcopal Value Plan |  |
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