Page 55 - 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 $300.00
MAXIMUM YOU PAY FOR HEALTH SERVICES
Maximum you pay for health services $8,500 In and Out-of-network
$4,800 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: 30%
coinsurance per visit
Specialist visit In-network: $45 copay per
visit
Out-of-network: 30%
coinsurance per visit
