Coverage	Preferred Network1	In-Network	Out-of-Network
Deductible	N/A	N/A	Individual - $2,000 Family - $4,000
Out-of-Pocket Maximum (accumulates separately for in- and out-of-network)	Individual - $2,500 Family - $5,000	Individual - $2,500 Family - $5,000	Individual - $3,000 Family - $6,000
Routine Physical Exams (includes all preventive services covered under the Patient Protection & Affordable Care Act)	Covered in full	Covered in full	20% coinsurance after deductible is met
Non-Routine Primary Care Provider Office Visits	$20 copay per visit	$20 copay per visit	20% coinsurance after deductible is met
Non-Routine Specialist Office Visits and Chiropractic Care	$20 copay per visit	$20 copay per visit	20% coinsurance after deductible is met
Physical/ Occupational/ Speech Therapy	Covered in full	$40 copay per visit	20% coinsurance after deductible is met
Inpatient Hospital Care and Surgery	Covered in full	$500 copay per admission	20% coinsurance after deductible is met
Inpatient Maternity Care	Covered in full	Covered in full	20% coinsurance after deductible is met
Diagnostic Imaging (x-rays, ultrasounds)	Covered in full	$50 copay	20% coinsurance after deductible is met
Diagnostic Blood Work	Covered in full2	$25 copay	20% coinsurance after deductible is met
Diagnostic Colonoscopies3	Covered in full	$200 copay	20% coinsurance after deductible is met
Inpatient Rehabilitation (limit 100 days per year)	Covered in full	$500 copay	20% coinsurance after deductible is met
Inpatient Behavioral Health & Chemical Dependency	Covered in full	Covered in full	20% coinsurance after deductible is met
High-Tech Imaging (CAT scan, MRI/MRA, nuclear nardiology, PET scan)	Covered in full	$50 copay	20% coinsurance after deductible is met
Durable Medical Equipment	Covered in full	$40 copay per provider per day	20% coinsurance after deductible is met
Outpatient Day Surgery	Covered in full	$300 copay	20% coinsurance after deductible is met
Urgent Care Center	$30 copay per visit	$30 copay per visit	20% coinsurance after deductible is met
Emergency Room	$100 copay per visit	$100 copay per visit	$100 copay per visit

¹Preferred Network includes Rhode Island Hospital and its pediatric division, Hasbro Children’s Hospital; The Miriam Hospital; Newport Hospital; Bradley Hospital; Lifespan Home Medical, Gateway Healthcare, and related service locations. For a list of all providers in this network, use the Find a Doctor tool.

²A copay will apply if your lab specimen is sent out to any non-Lifespan Lab for processing.

³Preventive colonoscopies are covered once every 5 years.

This is a summary of benefits. It is not a contract. For details about coverage, including any limits and exclusions not noted here, please call (401) 429-2102 or 1-866-987-3706.