Retirees and Dependents under Age 65 enrolled in the Exclusive Care Select Non-Medicare Plan. Call 1-800-962-1133 for additional information. The table consists of multiple rows with 4 columns, one column for Coverage Type, one for Tier 1 cost, one for tier 2 cost and one column for tier 3 costs.

Retirees & Dependents Under Age 65 Exclusive Care Select Non-Medicare Call 1-800-962-1133 for additional information
Coverage Type	Tier 1- Exclusive Care Network	Tier 2- National Network of Providers	Tier 3- Non-Network Providers
Annual Out-Pocket Maximum for Certain Services	$1,500/person $4,500/family	$2,500/person $7,500/family	$5,000/person $15,000/family
Primary Care and Specialist Physician Office Visits	$10/primary care $20/specialist	$25/primary care $50/specialist	60% of Allowable Charges (AC)
Inpatient Hospital Services (Mandatory Centers of Excellence apply)	90%	80%	60% of AC
Outpatient Facility Services (Mandatory Centers of Excellence apply to some Outpatient Facility)	90%	80%	60% of AC
Hospital Emergency Room or Outpatient Facility (Mandatory Centers of Excellence apply to some Outpatient Facility)	$50 co-pay, then 90%	$100 co-pay, then 80%	$100 co-pay, then 80% of AC
Urgent Care Facility	$20 co-pay	$50 co-pay	60% of AC
Rehabilitative Therapy	90%	80%	60% of AC
Durable Medical Equipment	90%	80%	60% of AC
External Prosthetic Appliances	90%	80%	60% of AC
Home Health Services (Up to 26 days/year)	90%	80%	60% of AC
Hospice Services	90%	80%	60% of AC
Skilled Nursing and Rehabilitation Facilities (100 visits maximum per member per contract year)	90%	80%	60% of AC
Laboratory and Radiology Services	90%	80%	60% of AC
Mental Health Inpatient Services Mandatory Centers of Excellence apply	90%	80%	Not Covered
Mental Health Outpatient Services (30 days maximum per member per contract year, unless Severe Mental Illness; Mandatory Centers of Excellence apply)	$20 co-pay		Not Covered
Substance Abuse Detoxification Inpatient Services (3-5 day max as medically necessary, one episode/lifetime; Mandatory Centers of Excellence apply)	90%	80%	Not Covered
Substance Abuse Detoxification Outpatient Services (30 days maximum per member per contract year; Mandatory Centers of Excellence apply)	$20 co-pay		Not Covered
Vision Care: Eye Exam	$10 co-pay	$25 co-pay	Not Covered
Vision Care: One Pair of Approved Glasses	Not Covered
Participating Retail Pharmacy	Generic: $15 co-pay Brand-name formulary: $25 co-pay Non-formulary Brand: $40 co-pay Significant or new therapeutic class drugs: 50%
Participating Mail-Order pharmacy (up to a 90 day supply) Mail-order is MANDATORY for maintenance medications	Generic: $30 co-pay Brand-name formulary: $50 co-pay Non-formulary Brand: $80 co-pay
This is a summary of the frequently asked about benefits. This chart is not meant to be a comprehensive explanation of benefits, cost sharing, exclusions or limitations. For a complete explanation of benefits, please refer to the Summary Plan Document (SPD). "Allowable Charges" is defined as "The allowed amount determined by the Plan to be payable for services rendered by out-of-network (Tier 3) providers. This allowed amount is based on a fee schedule established by Exclusive Care which may be modified by Exclusive Care at any time at its sole discretion. If a Tier 3 provider charges you more than the Allowable Charges covered by the Plan, you will have to pay the excess amount. That amount will not be applied toward your deductible or out-of-pocket limit.