Covered Benefits: Other Services


	Plan's Coinsurance Percentage for In-Network Care	Plan's Coinsurance Percentage for Out-of-Network Care*
Other Services
Ambulance Services (for sudden and serious medical conditions approved by your health care company as required for emergency care — also see "If You Need Emergency Care")	80% coverage after deductible	80% coverage after the in-network deductible
Emergency Room (for sudden and serious medical conditions approved by your health care company as required for emergency care — also see "If You Need Emergency Care") In accordance with applicable regulations, true emergency is determined based on what a prudent layperson would consider an emergency, not on the final diagnosis reached by doctors.	80% coverage after deductible for true emergencies**; 50% coverage after deductible for non-emergencies	80% coverage after in-network deductible for true emergencies; 50% coverage after in-network deductible for non-emergencies; Note: the in-network deductible applies for true emergencies**, rather than the out-of-network deductible
Durable Medical Equipment and Prosthetics (includes certain*** glucose monitors, insulin pumps and related pump supplies)	80% coverage after deductible	50% coverage after deductible
Prescription Drugs	Please see "The Prescription Drug Plan."
X-rays and Labs (when performed to diagnose a medical problem or treat an illness or injury)	80% coverage after deductible	50% coverage after deductible

* Covered out-of-network expenses are subject to reasonable and customary (R&C) charges. You are responsible for paying any charges above the R&C amount.

** True emergency as determined based on what a prudent person would consider an emergency, not on the final diagnosis reached by doctors.

*** Some glucose monitors and insulin pumps are available under the Prescription Drug Plan. For information on which insulin pumps are covered under the Medical and/or Prescription Drug Plan, please contact the appropriate provider (Aetna/Cigna and/or CVS Caremark)