Page 67 - Appendices for Eric Hartman
P. 67
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 $8,950 In and Out-of-network
$3,900 In-network
CONTACT INFORMATION
Plan address 1100 W Town and Country Rd Suite 1300
Orange, CA 92868
Bene ts & Costs
DOCTOR SERVICES
View Provider Network Directory
Primary doctor visit In-network: $5 copay per visit
Out-of-network: $40 copay
per visit
Specialist visit In-network: $20 copay per Limits apply
visit
Out-of-network: $50 copay
per visit
