$250 for Tier 4, Tier 5
Maximum out-of-pocket 
responsibility 
The most you pay for copays, 
coinsurance and other costs for 
covered medical services for the 
year. $2,200 in-network  
$2,200 combined in- and out-of-network  
Covered Medical and Hospital Benefits 
IN-NETWORK OUT-OF-NETWORK 
ACUTE INPATIENT HOSPITAL CARE 
N/A $500 copay per day for days 1-5 
$0 copay per day for days 6-90 
Your plan covers an unlimited 
number of days for an inpatient 
stay. $500 copay per day for days 1-5