| Benefit | Coverage |
|---|---|
| Lifetime maximum benefit | $2 million combined in and out of network |
| In Network | |
| Annual deductible | $900 individual, $1,800 family |
| Annual out-of-pocket maximum | $2,700 individual, $5,400 family (Excludes deductible) |
| Physicians' office visits | $35 copay (PCP), $45 (specialist) |
| Diagnostic x-rays, lab tests, and procedures (non-routine) | 75% |
| Hospital services | 75% after $100/day deductible; $600 maximum per admission; not subject to annual deductible |
| Out of Network | |
| Annual deductible | $1,800 individual, $3,600 family |
| Annual out-of-pocket maximum | $5,400 individual, $10,800 family (Excludes deductible) |
| Physicians' office visits | 50% after deductible |
| Diagnostic x-rays, lab tests, and procedures (non-routine) | 75% |
| Hospital services | 50% after deductible |
For details, download this benefits summary:
| Publications | View |
|---|---|
| Benefits Summary: 2008-09 Empire BCBS 75/50 PPO |  |
| Plan Handbook: 2008-09 Empire BlueCross BlueShield 75/50 PPO | |
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