Page 63 - APPENDICES for Vic Bosiger
P. 63
DEDUCTIBLES
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Health deductible $0
Drug deductible $0.00
MAXIMUM YOU PAY FOR HEALTH SERVICES
Maximum you pay for health services $10,000 In and Out-of-network
$5,900 In-network
CONTACT INFORMATION
Plan address 500 West Main Street
Louisville, KY 40202
Bene ts & Costs
DOCTOR SERVICES
View Provider Network Directory
Primary doctor visit In-network: $0 copay
Out-of-network: 40%
coinsurance per visit
Specialist visit In-network: $35 copay per
visit
Out-of-network: 40%
coinsurance per visit
