Page 33 - APPENDICES for Diane Falten
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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 $7,050 In and Out-of-network
$7,050 In-network
CONTACT INFORMATION
Plan address P.O. Box 9746
331 Veranda Street
Portland, ME 04104
Bene ts & Costs
DOCTOR SERVICES
View Provider Network Directory
Primary doctor visit In-network: $0 copay
Out-of-network: $35 copay
per visit
Specialist visit In-network: $40 copay per Limits apply
visit
Out-of-network: $55 copay
per visit
