In Network |
Out of Network |
Copay |
No Charge after Deductible |
50% after Deductible |
Office Visits |
No Charge after Deductible |
50% after Deductible |
Annual Deductible |
Individual: $5,500 Family: $11,000 |
Individual: $10,000 Family: $20,000 |
Annual Out-Of-Pocket Limit |
Individual: $5,500 Family: $11,000 |
Individual: $12,500 Family: $25,000 |
Lifetime Maximum |
Not Applicable |
Not Applicable |
Prescription Drugs |
Generic/Preferred Brand: No Charge after Medical/Rx Deductible, Non-Preferred Brand: Not Covered
|
Generic/Preferred Brand: 50% after Medical/Rx Deductible, Non-Preferred Brand: Not Covered |
Laboratory & X-Ray |
No Charge after Deductible (Non-Preventive)
|
50% after Deductible (Non-Preventive)
|
Annual Physical Exam |
No Charge |
50% after Deductible
|
Annual OB-GYN Exam |
No Charge |
50% after Deductible
|
Well Baby Care |
No Charge (Age and frequency limits apply) |
50% after Deductible
(Age and frequency limits apply) |
Outpatient Surgery |
No Charge after Deductible |
50% after Deductible |
Emergency Room |
No Charge after Deductible |
No Charge after Deductible |
Inpatient Hospital |
No Charge after Deductible |
50% after Deductible |
Ambulance |
No Charge after Deductible
|
No Charge after Deductible |
Home Health Care |
No Charge after Deductible (30 visits/calendar year; In and Out-of-Network combined)
|
50% after Deductible (30 visits/calendar year; In and Out-of-Network combined)
|
Mental Health - Outpatient |
Not Covered |
Not Covered |
Chiropractic Care |
No Charge after Deductible (24 visit max; $25 per visit max)
|
50% (24 visit max; $25 per visit max)
|
Acupuncture |
See Brochure |
See Brochure |
Mental Health - Inpatient |
Not Covered |
Not Covered |
Chemical Dependency |
No Charge after Deductible |
50% |
Maternity Care |
Not Covered (except for pregnancy complications)
|
Not Covered (except for pregnancy complications)
|