Policy Information

Deductible: $$2,500\mathrm{.}00$

Copayments: $($Only the services listed below are copayments $-$ All others services are coinsurance$)$

In$-$Network Primary Care Physician Office Visit: $$25\mathrm{.}00$

In$-$Network Specialist Physician Office Visit: $$35\mathrm{.}00$

In$-$Network Emergency Department Visits: $$500\mathrm{.}00$

In$-$Network Outpatient Therapy Visit: $$50\mathrm{.}00$

Urgent Care Center Visit: $$75\mathrm{.}00$

Outpatient Surgery Center $$750\mathrm{.}00$

Coinsurance: $,\frac{70}{30}\%($All other healthcare services are paid under coinsurance$)$

Maximum Out$-$Of$-$Pocket $($OOP$)$: $$4,500\mathrm{.}00$

$3.$ Jessalyn went to the emergency department. The allowed payment for hospital is $$4,576\mathrm{.}98.$ How will the payment to the hospital take place?

Patient's Annual Year$-$to$-$Date Summary Prior to This Encounter:

Toward Deductible: $$2,400\mathrm{.}00$

Remaining Maximum OOP: $$785\mathrm{.}22$

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