$200 for Tier 3, 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. $6,700 in-network  
$10,000 combined in- and out-of-network  
Covered Medical and Hospital Benefits 
IN-NETWORK OUT-OF-NETWORK 
ACUTE INPATIENT HOSPITAL CARE 
N/A $750 copay per admit 
Your plan covers an unlimited 
number of days for an inpatient 
stay. 30% of the cost 
OUTPATIENT HOSPITAL COVERAGE 
Outpatient surgery at