Hospital Inpatient Services

Hospital Admission Room & Board

PPO: $100 deductible per admit, 90% of next $5,000, then 100% thereafter

Non-PPO: $500 calendar year deductible plus $1,000 admit deductible, 50% of UCR with no out-of-pocket annual maximum

Routine Nursery Care

PPO: $100 deductible waived, 90% of first $5,000, then 100% thereafter
Non-PPO: Deductibles waived, 50% of UCR

Newborn Extended Stay

PPO: $100 deductible per admit, 90% of next $5,000, then 100%

Non-PPO: $250 calendar year deductible plus $600 per admit, 50% of UCR with no out-of-pocket annual maximum

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