Major Medical Copay 3500 Premier

Tier 1 Preferred benefits require contacting the Care Coordination team before getting services; if you book an appointment with a recommended provider, care is free, but Tier 1 benefits are not guaranteed. Hospital services use reference-based pricing (Maximum Allowable Charge based on Medicare-published costs plus an additional percentage); excess charges are not counted toward the deductible or out-of-pocket maximum. The out-of-pocket limit never includes premium, balance-billed charges, services the plan doesn't cover, or penalties. Prior authorization required for labs/imaging, hospital stays, outpatient procedures, and rehabilitation; a 25% payment reduction penalty may apply at the plan's discretion if non-recommended providers are used for non-emergent services. Out-of-network services generally not covered except emergency room and ambulance. Rehabilitation & Habilitation combined limit of 30 days per plan year. Amaze virtual mental health: spouse and children under 26 eligible even if not on the plan. Supplemental Critical Illness: 30-day waiting period applies; spouses receive 100% of the benefit, children 50%.