Pharmacy (Part D) deductible This plan does not have adeductible. 
Maximum out-of-pocket 
responsibility $2,750 in-network 
The most you pay for copays, coinsurance and other costs for medical 
services for the year. 
Covered Medical and Hospital Benefits  
Acute inpatient hospital care $150 copay per day for days 1-8 
$0 copay per day for days 9-90 
Your plan covers an unlimited number of days for an inpatient stay. 
Outpatient hospital coverage •Outpatient surgery at Outpatient Hospital:  $150 copay