Page 75 - APPENDICES for Diane Falten
P. 75
DEDUCTIBLES
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Health deductible $0
Drug deductible $275.00
MAXIMUM YOU PAY FOR HEALTH SERVICES
Maximum you pay for health services $9,500 In and Out-of-network
$7,000 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: 30%
coinsurance per visit
Specialist visit In-network: $50 copay per
visit
Out-of-network: 30%
coinsurance per visit
