| In Network |
Out of Network |
Copay |
20% after Deductible or Not Covered |
50% after Deductible or Not Covered |
Office Visits |
Not Covered |
Not Covered |
Annual Deductible |
Individual: $3,000 Family: $6,000 |
Individual: $6,000 Family: $12,000 |
Annual Out-Of-Pocket Limit |
Individual: $5,000 Family: $10,000 |
Individual: $10,000 Family: $20,000 |
Lifetime Maximum |
Not Applicable |
Not Applicable |
Prescription Drugs |
Not Covered
|
Not Covered |
Laboratory & X-Ray |
Not Covered |
Not Covered |
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 |
20% after Deductible |
50% after Deductible |
Emergency Room |
$100 (waived if admitted) plus 20% after Deductible |
$100 (waived if admitted) plus 20% after Deductible |
Inpatient Hospital |
20% after Deductible |
50% after Deductible |
Ambulance |
20% after Deductible |
20% after Deductible |
Home Health Care |
20% 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 |
Not Covered |
Not Covered |
Acupuncture |
See Brochure |
See Brochure |
Mental Health - Inpatient |
Not Covered |
Not Covered |
Chemical Dependency |
20% |
50% |
Maternity Care |
Not Covered (except for pregnancy complications)
|
Not Covered (except for pregnancy complications)
|
