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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

Preauthorization required for non-emergent outpatient diagnostic imaging services, including magnetic resonance imaging/magnetic resonance angiogram (MRI/MRA); positron emission tomography (PET); computed tomography(CT), including cardiac CT/CTA and EBCT; and nuclear cardiology.


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