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Your in-network deductible is $3,500 per person. Your out-of-network deductible is $7,000 per person. The deductible does not apply to preventive care or to primary care, specialist and urgent care copays. Your in-network out-of-pocket limit is $8,000 per person, and the out-of-network limit is $16,000. Copays, coinsurance and amounts you pay toward the deductible count toward the out-of-pocket limit. Premiums, balance-billed charges and services this plan doesn't cover do not.

Primary care visit to treat an injury or illness: $30 copay in-network; 50% coinsurance after the deductible out-of-network. Specialist visit: $60 copay in-network; 50% coinsurance after the deductible out-of-network. You do not need a referral to see a specialist. Preventive care, screenings and immunizations: no charge in-network.

Diagnostic tests such as x-rays and blood work: 30% coinsurance after the deductible in-network; 50% coinsurance after the deductible out-of-network. Imaging such as CT, PET and MRI scans: 30% coinsurance after the deductible in-network; 50% coinsurance after the deductible out-of-network. Prior authorization is required for CT, PET and MRI scans.

Urgent care: $75 copay in-network; 50% coinsurance after the deductible out-of-network. Emergency room care: $400 copay per visit, in-network and out-of-network. The emergency room copay is waived if you are admitted to the hospital.

Outpatient physical, occupational and speech therapy: $60 copay per visit in-network; 50% coinsurance after the deductible out-of-network. Coverage is limited to 30 visits per calendar year for all therapies combined.

This plan does not cover: acupuncture; bariatric surgery; cosmetic surgery; hearing aids; long-term care; non-emergency care when traveling outside the U.S.; routine foot care; weight loss programs.

Some services need approval from the plan before you receive them. Your in-network provider requests prior authorization for you. Services that need prior authorization include CT, PET and MRI scans, inpatient admissions that are not emergencies, and outpatient surgery. If you use an out-of-network provider, you are responsible for getting prior authorization. Without it, the plan may reduce or deny payment.

Out-of-network providers have no contract with the plan and may bill you for the difference between their charge and the plan's allowed amount. This is called balance billing. Balance-billed amounts do not count toward your deductible or out-of-pocket limit. The No Surprises Act protects you from balance billing for emergency care and for certain care at in-network facilities.