What does the GAP cover?

The following out-of-pocket expenses are covered:

Maximum In-Hospital Benefit:

• Up to $1,000 per hospital confinement

Maximum Out-patient Benefit:

• Treatment in a hospital emergency room

• Out-patient surgery in a hospital out-patient facility or free-standing out-patient surgery center

• Diagnostic testing in a hospital out-patient facility or MRI facility

• Up to $200 for treatment of the same or related conditions unless separated by a period of 90 consecutive days (then a new out-patient benefit will be payable)

Physician Out-patient Treatment Benefit:

• Treatment in a hospital out-patient clinic, free-standing emergency care clinic or physician’s office

• Up to $25 per treatment; $125 maximum per family per calendar year (non-routine care excluded)