EFTA00316273Set 9
2016-08-259p3,112w
costs up to the deductible amount before this plan begins to
leductible? Non-Network: $500 Indiv / $1,000 Family pay for covered services you use. Check your policy or plan ... most you could pay during a coverage period
not-of-. ocket limit Non-Network $5,000 Indiv I $10,000 Family (usually one year) for your share of the cost ... limited to 20 visits per policy period.
Pre-Notification required for non-network or benefit reduces to
50% of allowed.
Preventive No Charge Not Covered No coverage non-Network.
care/screening/immunizati-
https://www.justice.gov/epstein/files/DataSet%209/EFTA00316273.pdf