Out of Pocket (Stop Loss)
Coverage Level: Family
Service Type: Health Benefit Plan Coverage
Insurance Type Code: HM Health Maintenance Organization (HMO)
Time Period Qualifier: Remaining
Amount: $16,190.82
In Plan Network Indicator: Unknown

Non-Covered
Coverage Level: Individual
Service Type: Medical Care
Insurance Type Code: HM Health Maintenance Organization (HMO)
Plan Coverage Description: Fidelis Care Silver
In Plan Network Indicator: No
Message: Medical Care
Non-Covered
Coverage Level: Individual
Service Type: Durable Medical Equipment Purchase
Insurance Type Code: HM Health Maintenance Organization (HMO)
Plan Coverage Description: Fidelis Care Silver
In Plan Network Indicator: No
Message: DME Purchase