Download Extended Medical Expense Benefit Covered extended

Extended Medical Expense Benefit
Covered extended medical expenses are defined as the reasonable and customary charges for
covered medical services performed, or supplies prescribed by a doctor, except as otherwise
provided due to your sickness, injury or pregnancy.
These services and supplies must be medically necessary in terms of generally accepted
medical standards as determined by the Plan. No more than the reasonable and customary
charge for medical services and supplies will be covered by this Plan.
The subscriber is responsible for the difference between the provider's charge and the
reasonable and customary charge, along with any applicable deductible and coinsurance.
The Plan will pay extended medical expense benefits to the extent covered medical expenses in
a calendar year exceed the deductible and coinsurance.
Terms of the extended medical expense benefit are:
Individual Annual Deductible: $1,000 Maximum Family Annual Deductible: $3,000
Coinsurance: 30%
Out of Pocket Maximum*: $3,250per person and/or family per calendar year plus
Deductibles
Plan Benefit Paid: 70% of Usual Customary and Reasonable Charge unless
otherwise specified
Annual Lifetime Extended Medical
Expense Benefit Maximum: Unlimited
Full-Time Student Eligibility: Ages 19 – 26
*Only eligible benefits will accumulate toward the out-of-pocket maximum. In other words,
nonparticipating providers' charges in excess of UCR will not apply to the out-of-pocket
maximum. This will not affect a participating provider, because they must accept the fee
schedule as payment in full.
The potential out-of-pocket expenses incurred by an individual could be $1,300. This includes
the annual deductible of $300 and the out-of-pocket maximum of $1,000 if the individual used
the services of a non-participating provider.
The potential out-of-pocket expenses incurred by a family could be $1,900. This includes the
annual deductible of $900 and the out-of-pocket maximum of $1,000 if the family used the
services of a non-participating provider.
This does not include any co-payments or deductibles made for prescription drugs and/or
participating provider services.